SYLLABUS OF NOTES 



LECTURES 



Theory^Pragtige of Medicine 



DELIVERED BEFORE THE STUDENTS OF THE UNIVERSITY 
OF PENNSYLVANIA, 

y by 

WILLIAM PEPPER, M. D., LL. D. 



Provost and Professor of the Theory and Practice of Medicine, 
Professor of Clinical Medicine, etc., etc . 





PREPARED (BY SPECIAL PERMISSION') FOR THE USE OF 
STUDENTS IN THE UNIVERSITY 

BY 

CUTHBERT BOWEN, B.A. 

Late Exhibitioner, Coleridge Prizeman and Honour Classman, University of Durham. Matriculate of 

London University. Member of the H. C. Wood Medical Society. One of the 

Assistants to the Demonstrator of Anatomy, Medical 

Department University of Pa. 



'86 - '87. £ 

acnW 



PHILADELPHIA: 
Press of Burk & McFetridge, 306 and 30S Chestnut Street. 

1886. 



^*2v 



Copyright, 1886, by Cuthbert Bowen, B. A. 



\D 



PREFACE. 



This little work being simply a reproduction of a student's private note 

book, which through the kind courtesy of Dr. Pepper he has received 

permission to submit to his fellow students in a printed form, it must be 

understood that for all inaccuracies and misrepresentations of the lecturer's 

actual statements which may be found therein, the compiler alone is directly 

responsible. 

CUTHBERT BOWEN. 



CONTENTS. 



PART I. 



I. DISEASES OF THE NERVOUS SYSTEM. 

I. General Considerations, (i.) Symptoms; (2.) Causes; (3.) Diagnosis. 

II. Diseases of the Membranes. Meningitis. (1.) Tubercular Lepto-Menin- 
gitis; (2.) Idiopathic Meningitis; (3.) Chronic Cerebral Meningitis; 
(4.) Cerebro-Spinal Meningitis ; (5.) Spinal Meningitis. Hydrocephalus. 

III. Affections of the Cerebrum. Anaemia. Congestion. Thrombosis. 

Embolism. Softening. Hemorrhage. Apoplexy. (1.) Simple; 
(2.) Marked; (3.) Fatal 

IV. Affections of the Spinal Chord. Congestion. Thrombosis. Embolism. 

Hemorrhage. Softening. Sclerosis. — (1.) Lateral; (2.) Posterior; 
(3.) Disseminated. Myelitis. — Anterior or Polio-Myelitis 

V. Affections of the Peripheral Nerves. Neuralgia .... 

VI. Epilepsy 

VII. Chorea or St. Vitus' Dance 

II. DISEASES OF THE KIDNEY. 

I. The Urine, (i.) Quantity; (2.) Quality; (3) Color. Anuria. Diuresis. 
Diabetes. (4.) Specific Gravity; (5.) Reaction; (6.) Detection of 
Abnormalities. Phosphatic Diathesis. Uric Acid Diathesis. Lithaemia 
Oxaluria ............ 

II. Renal Calculi, (i.) In Substance; (2.) In Pelvis; (3.) Occlusion of 
Ureter. Pyelitis .......... 

III. Congestion, (i.) Acute; (2.) Chronic. Bright's Disease. Acute and Chronic, 

Chronic Catarrhal Nephritis. Chronic Interstitial Nephritis. Amyloid 
Degeneration. Fatty Degeneration ...... 

IV. Uraemia 

V. Albuminuria. Hematuria. Haemoglobinuria. Chyluria 
VI. Morbid Growths. Hydronephrosis. Cancer. Perinephritis. 

III. DISEASES OF THE HEART AND BLOOD VESSELS. 

I. The Pericardium. Pericarditis. Acute and Chronic 

II. The Heart. Hypertrophy. Simple. Eccentric. Cojtcentric. Dilata- 
tion. Fatty Degeneration. Angina Pectoris. Palpitation 

III. The Endocardium. Endocarditis. {I.) Acute. (1.) Ordinary ; (2.) Ulcer- 

ative. Embolism. (II.) Chronic. (1.) Mitral Regurgitation and 
Stenosis; (2.) Aortic Regurgitation and Stenosis; (3.) Tricuspid Re- 
gurgitation; (4.) Pulmonary Stenosis ....... 

IV. The Circulation. Aneurism. Exophthalmic Goitre. Anaemias. (1.) Simple 

(2.) Toxic. Malarial and Metallic. Leuccemia. Pseudo-Leuccemia. 
Chlorosis ............ 



VI 

IV. DISEASES OF THE SPLEEN. 

Splenic Enlargement. Rupture. Inflammation. -Cancer. Hydatids of the 
Spleen 

V. DISEASES OF THE RESPIRATORY TRACT. 

I. The Nose. Nasal Catarrh. (I.) Acute; (2.) Chronic . 

II. The Larynx. Laryngitis. (l.) Catarrhal ; (2-) (Edematous ; (2.) Ulcer- 
ative ; (4.) Tuberculous; (5.) Syphilitic. Croup. (1.) Spasmodic or 
False ; (2.) Membranous or True. Tumors of the Larynx. Cancer . 

III. The Bronchi and Trachea. Bronchitis. Mechanical. Secondary. 

Fibrinous. Capillary. Rheumatic. Chronic Bronchitis. Winter Cough, 
Emphysema. Dilatation of the Bronchial Tubes. Asthma . 

IV. The Lungs. Atelactasis. Hypostatic Congestion. Pneumonia. Catarrhal, 

Croupous. Bilious. Cerebral. Malarial. Typhoid. Secondary. 
Pulmonary Phthisis. Catarrhal. Fibroid. Galloping Consumption . 

V. The Pleura. Pleurisy. Simple Acute. Plastic. Diaphragmatic. Purulent. 
Hydro-Thorax. Pneumo-Thorax. ....... 

VI. DISEASES OF THE DIGESTIVE TRACT. 

I. The Mouth. Stomatitis. (1.) Aphthous; (2.) Ulcerative . 

II. The Throat. Tonsilitis. (1.) Simple; (2.) Herpetic ; {^Phlegmonous* 
Quinsy. Hypertrophy of Tonsil. Retro-Pharyngeal Abscess. Phar- 
yngitis. (1.) Catarrhal ; (2.) Follicular; (3.) Ulcerative ; (4.) Phleg- 
monous ; (5.) Tziberculotis. Chronic Sore Throat .... 

III. The (Esophagus, (i.) Spasm; (2.) Obstruction; (3.) Paralysis . 



PART II. 



IV. The Stomach. Gastralgia. Dyspepsia. (I.) Chronic; (2.) Catarrhal; 
(3.) Nervous. Ulceration. Cancer. Obstruction of the Pylorus. Dilatation. 

V. The Peritoneum. Peritonitis. (1.) Local; (2.) General ; (3.) Chronic. 

VI. The Intestines. Typhlitis. Perityphlitis. Obstruction of the Bowels. 
Intestinal Neuralgia. Intestinal Dyspepsia, (i.) Atonic ; (2.) Catarrhal ; 
(3.) Nervous. Diarrhoea, Catarrhal. (i.) Acute ; (2.) Chronic; 
Craptilous. Lienteric. Bilious. Colliquative. Ulcerative. Dysentery : 
Bilious, Malarial, Typhoid, Malignant. Choleraic Affections. Asiatic 
Cholera. Cholera Morbus. Cholera Infantum ..... 

VII. The Gall Bladder. (i.) Inflammation; (2.) Dropsical Distention; 
(3.) Formation of Gall Stones ; (4.) Growth of Neoplasms. Jaundice. 

VIII. The Liver. Hepatalgia. Congestion. Hepatitis. Abscess. Cirrhosis. 
Ascites. Cancer. Syphilis of Liver. Amyloid Degeneration. Fatty 
Liver. Hydatid Tumors. Acute Yellow Atrophy. .... 

VII. THE FEVERS. 

Ephemeral. Simple Continued. Typhus. Typhoid. Small Pox. Scarlet 
Fever. Measles. Rotheln. Chicken Pox. Whooping Cough. Influenza. 
Malarial Diseases. Intermittent and Remittent Fever. Mumps. Diph- 
theria. Erysipelas .......... 

VIII. CONSTITUTIONAL DISEASES. 

Rheumatism, (i.) Acute. (2.) Chronic. Gout. Arthritis Deformans. 
Rickets 



PART I. 



I. DISEASES OF THE NERVOUS SYSTEM. 

Nervous Diseases may be divided into two main classes, i. Functional, 
in which we have a disturbance of the part, but are unable to observe any- 
anatomical changes in the structure of the nerve substance. 2. Organic, 
which are associated with definite anatomical change. It may be doubted, 
however, whether there is not always present some minute change in the 
structure of the nerve, even though we are not able to detect it microscopi- 
cally. Of nervous diseases those which we are accustomed to regard as 
Functional are by far the more numerous. We may further divide the dis- 
eases of the Nervous System into Acute and Chronic, using the terms in their 
ordinary signification. 

The diagnosis of Nervous Diseases is extremely difficult. Hysterical 
patients simulate the symptoms of the most complex nervous disorders, 
and this condition must be eliminated first in making a diagnosis. Again, 
we must ask ourselves whether the symptoms present can be explained as 
purely hysterical or is hysteria associated with some other nervous disorder, 
as is often the case. Neurasthenia may exist either with or without hyste- 
ria. This renders the diagnosis extremely difficult and perplexing. Toxic 
Agencies may simulate nervous diseases, e. g., Malaria, Arsenic, Lead and 
Copper, and the blood-poison of Septic Fever. 

All these must be excluded before determining the organic symptoms. 

ORGANIC AFFECTIONS. 

By the term Nervous System we understand the Brain, Spinal Chord 
and Nerve-Trunks, with their respective Membranes. They are cellular, vas- 
cular structures, with a more or less fibrous basis. Each portion of the ner- 
vous system is subject to distinct diseases. The Sheaths of the nerve-trunks 
are liable to Permeuritis ; the Membranes of the brain and chord to 
Meningitis. 

The Nerve-Cells are liable to Degeneration and Atrophy ; and, as they 
exert an influence over nutrition, we find serious diseases following lesions 
of the cells themselves. 

The Nerve-Fibres are also liable to lesions produced by inflammation, 
which may be either Acute or Chronic. This often ends in destructive 
changes, e.g., Abscess or Softening. Sometimes it causes Contraction, with 
Atrophy of the fibres, and an Increase of the Interstitial Connective Tissue, 
which we term Sclerosis. This is a very common change. Sclerosis, how- 
ever, is not always the result of inflammation. It may result from a slow 
wasting of the fibres or a slow overgrowth of the tissue, without inflammation. 



Thrombosis-, Embolism and Hemorrhage are frequent accompani- 
ments of nervous diseases. By Thrombosis we understand the formation of a 
clot in a venous trunk. Embolism is the plugging of an arterial trunk by 
a clot orbit of fibrin driven into it. Hemorrhage is more common in con- 
nection with the brain than with the Spinal Chord. This is also the case 
with the other two. These three lesions are intimately connected with 
Softening, which may result from either one of them. 

Tumors frequently appear in connection with diseases of the nervous 
system. 

The chief lesions, to enumerate them, may be said to be: — 
i. Anaemia, 

2. Congestion, 

3. Inflammation (Acute or Chronic), 

4. Embolism, 

5. Thrombosis, 

6. Hemorrhage, 

7. Softening, and 

8. Sclerosis. 

While we observe that the number of lesions is not very great, we find 
that the Symptoms which they give rise to are extremely numerous. We 
have: — 

1. Pain which is very common, and may be either Centric, i. e., referred to 
the line of the nervous system, or Eccentric, i. e., referred to other parts. 
Centric pain, in the case of cerebral disease, is located by the patient in the 
brain itself. Pains vary extremely in character. We speak of — 1. Girdle 
pain; the patient feels hooped in, as by a circle, at the point of the disease. 
These are examples of what are termed eccentric. 2. Radiating, i. e., along 
the nerve-trunks. 3. Darting or irregular. These fulgurant or lightning- 
like pains are very characteristic of Locomotor Ataxia. 

II. Many Disorders of General Sensibility. 1. Vertigo, or Dizzi- 
ness, is very common. There is a feeling of unsteadiness. The patient 
cannot balance himself, he feels that surrounding objects are moving while 
he himself is standing still. 2. Numbness in different parts of the body. 3. A 
feeling often described as "pins and needles." 4. Fonnication, i. e., a sensa- 
tion as though ants were crawling on the person. 

III. More or less Impairment of Sensation. 1. Anesthesia, which 
may be slight or marked. By it is meant the total or partial destruction of 
sensibility. Contact with a pin may not be perceived — hot and cold are 
not distinguishable. 2. Hyperozsthesia, i. e., exaggeration of sensibility. Of 
this there are several grades. 

IV. Disorders of the Special Senses. Among these the — 1. Eyes 
furnish most symptoms. We find — 1. Strabismus , or squint. 2. Photopho- 
bia, which is due to an exaggerated sensibility of the Retina. 3. Hemiopia; 
and 4. Double Sight. 5 . Impairme?ii of Vision in some form or the other 
is very common, and must be looked for. Again, the vision is sometimes 
very well preserved, even when, 6. Changes in the Optic Nerve or Retina are 
revealed by the opthalmoscope, 7. Inflammation and Afrophy of the Optic 
Nerve; and 8. VVasiing of the Retina are often indicative of brain trouble. 

2. Subjective sounds are referred to the Ears. Patients complain of 
Tinnitus. 3. We also have impairment of Taste and Smell. These, 
however, are not of very much moment. 

V. Disorders of Motion. Paralysis, i. e., loss of motor nerve power. 
This is independent of the muscles. A joint may be anchylosed, or a mus- 
cle be wasted, and yet no paralysis exist. This may be slight, marked or 



5 

absolute. We may have Local Palsy, as of the extensors of the forearm 
(e. g., from lead-poisoning) or of the External Rectus muscle of the eye. 
Paralysis of an entire member, or Monoplegia. This term is an objectionable 
one. Hemiplegia, or paralysis of half the body, either with or without the 
face. Paraplegia, or paralysis of the lower half of the body. Some persons 
cannot walk, yet, if placed on their back, they have full power in their legs. 
This comes from a want of co-ordination, which we term Ataxia. This may 
be found in any voluntary muscle whatever, and we must not regard it as a 
special disease, but only as a symptom. Sclerosis of the posterior columns 
of the chord is frequently referred to as Locomotor Ataxia. 

VI. Various Uncontrollable Movements, i. Fibrillar Contraction. 
This is the earliest symptom of Progressive Muscular Atrophy. 2. Tremor \% 
an important symptom in connection with disease of the chord. There are 
certain forms of Functional Tremor, as in Copper-Poisoning. This is entirely 
different from (3) the Spasmodic Jerking of the involuntary muscles which is 
seen in Chorea. Tremor is sometimes present when the muscle is not in 
use, but generally it only manifests itself on exertion. 

VII. Changes in Reflex Action. Reflex action is a response to stim- 
ulation at a distant point. It may be diminished, increased or entirely lost. 
We generally employ it, under the form of Ankle Clonus and Patella Reflex 
or knee jerk, in order to determine the existence or absence of certain ner- 
vous diseases. Patella Reflex is absent in Locomotor Ataxia. • It is 
increased in irritation of the Motor Columns of the Chord. 

VIII. Changes in the Electrical Condition of Muscles. This may 
be impaired, increased or lost. When muscles have undergone degeneration 
they lose the power of responding to electrical irritation. In health, mus- 
cles will not respond to the Galvanic Current as to the Faradic. This may 
be reversed in case of disease of the nerves. The electrical state of the mus- 
cles is a valuable guide in Prognosis. 

IX. Disorders of Circulation and Nutrition. The extremities may 
be hot with congestion and redness, or may be deathly cold. In one form 
of Xerve trouble we have a Pseudo-Hypertrophy of the muscle, though asso- 
ciated with muscular atrophy. In atrophy of the muscles, the Transverse 
Markings become dim. The fibres become granular. In some cases we 
find peculiar Cutaneous Eruptions, or Herpes. A close relation exists be- 
tween Eruptions and disease of the nerve-trunks. Clustered Herpes around 
the trunk with a tendency to spread is associated with injury to the inter- 
costal nerves. Racemose Herpes is associated with the Trifacial Nerve. 

X. Memory very often fails. 

XI. Disorders of Speech. These are frequent, and are of great import- 
ance. When articulate speech is lost we know we have a lesion in the left 
side of the brain in a limited area, near the Fissure of Sylvius. This 
condition is termed Aphasia. 

XII. Convulsions. These are sudden attacks, with or without uncon- 
sciousness, attended with uncontrollable spasmodic movements of various 
parts. They may themselves last many minutes, and be followed by hours 
of unconsciousness. They may be confined to a few or extend to many 
muscles. They are very characteristic of Epilepsy, and occur in many blood- 
poisons as Scarlet Fever, etc., and accompany many tumors of the brain, 
depressed fractures of the skull, etc. 

XIII. Disorders of Respiration. Cough may arise from Centric Irrita- 
tion. In some cases we have Hiwried Respiration, and, when there is pressure 
on the brain, Slowed Respiration. CJieyne-Stokes, or Tidal, or Ascending and 
Descending breathing, is met with in Tubercular Meningitis. It is sometimes 



noticed where there is actual trouble in the Pneumo-Gastric roots, e. g w , 
where there is pressure from an exudation, or where there is a change in the 
nerve-centres accompanying blood-poison, e. g. t in Uraemia. The pause 
between the inspirations may last ten, fifteen or even thirty seconds, and 
the breathing be even shorter than the pause. The deadened state of the 
brain does not perceive the need of respiration, and there is an accumulation 
of Carbonic Acid. This accumulates until it finally arouses the lethargic 
brain, but this energy soon dies, and the brain lapses back until there is 
another rally. This breathing is a very ominous sign. After recovery is 
very rare. 

XIV. The Circulatory System is affected where a tumor presses on 
the brain ; the Pulse may be slowed. It is often irregular or intermittent. 
Where we find these changes without heart trouble, we should think of the 
possibility of brain lesions. 

XV. Derangement of the Digestive Apparatus. Vomiting is often 
produced by centric irritation. Where we do not have enough Gastric trou- 
ble to account for its occurrence, we should think of brain tumor as a possi- 
bility. Where there is brain trouble we may have Constipation. On the 
other hand, we may have, as in Spinal Palsies, Incontinence of faeces, or the 
patient may be unable to void them, and then we have Retention. 

XVI. The Urinary Organs are Involved. We find Incontinence with 
involuntary constant dribbling, or there may be Retention. A central lesion 
near the floor of the Fourth Ventricle may give rise to Saccharine Diabetes. 

Causes which lead to Functional and Organic Diseases of Nerves: — 

I. Heredity. With the exception of Phthisis, in no other diseases is 
there a greater hereditary tendency. The children of Epileptic parents 
will have either Palsy or some form of mental derangement. Pseudo- 
hypertrophic paralysis runs in families. Several cases have been noted in a 
group of relations, and not so many in a million outside these. 

II. In no other class of disease does Traumatism have such effects. 
Epilepsy may often be traced to an old injury, which may be only revealed 
by trephining or at the post-?nortem. 

III. Over- Exertion, exhausting excessive labors. 

IV. Prolonged and Depressing Emotions, e.g., excessive indulgence 
in venery. 

V. Inordinate Use of Alcohol and Tobacco. 

VI. Atmospheric Influences. The Nervous System is liable to be 
influenced by violent vicissitudes of temperature, but still more by long 
exposure to cold. 

VII. The brain is especially liable to Syphilitic Disease, but the chord 
and nerves are also affected. Lesions from Syphilis will always yield to 
large doses of Iodide of Potassium. This distinguishes them from other 
similar lesions. By proper treatment a Syphilitic Gumma will be dispersed. 
This is not so with other tumors. 

VIII. Atheroma of Arteries is a fruitful source of Nerve Disease, lead- 
ing to Softening of the vessels. 

In the study of any Nervous Disease all the above causes must be looked 
for. In making our Diagnosis the first point is to distinguish Functional 
from Organic disease. We should study the History, Symptoms and the 
Mode of Development. Next we localize the disease. This is more im- 
portant in nerve diseases than in any others, except perhaps those of the 
heart. We then study the special function that is disturbed, and, having 
localized it, we determine its Pathological nature. 



Diseases of the Membranes : — 

Meningitis may be Cerebral, Cerebro-spinal or simply Spinal. The 
membranes are liable to Inflammation, under the names of Pachy-menin- 
gitis, Arachnitis and Lepto-meningitis. These are the accepted divisions. 
The First is inflammation of the thick outer membrane of the brain or 
Dura. It is especially met with in Trauma and disease of the bone, as in 
Caries. The Second, or inflammation of the Arachnoid, is rare as a separate 
affection. The Third may present itself as Tubercular Meningitis, or it may 
be Idiopathic. 

I. Tubercular Lepto- Meningitis is an inflammation of the Pia or 
Arachnoid space, accompanied with a deposit of tubercles. Its Causes are: 
i. Age. It is a disease of infancy, being comparatively rare after puberty. 
It is most frequent in the first three years, but occasionally occurs in adult 
life. It is influenced — 2. By Heredity. 3. By Tuberculous Diathesis. 
4. By a Tendency to Nervous Diseases. Especially does it occur in 
infants whose mothers are delicate or have a tendency to Phthisis. Such 
children should never be suckled by their mothers. 5. It is brought on by 
Dentition ; or 6. By a blow on the head. The essential lesions consist 
in the formation of grey, round, tuberculous granules in the meshes of the 
Pia Mater. These are found chiefly in the course of the small vessels con- 
nected with the sheaths. They seem to prefer the base of the brain, par- 
ticularly the Fissure of Sylvius, and back of the Crura of the brain and the 
Pons. Their formation is associated with congestion, inflammation and the 
production of lymph. At times this is copious. The lesions may extend 
into the Spinal Tract and involve the Chord. The Substance of the brain 
is congested. The outer layers show degeneration, and the lining of the 
ventricles is often roughened or softened with the too great effusion therein. 
Tubercles are often found in the Lungs, Spleen and Lymphatic Glands. In 
adults Tubercular Meningitis is never Primary, but always follows tubercles 
somewhere else. In children, however, it may be primary. 

The Symptoms are very characteristic indeed. We consider those 
of — 1. The Invasion. 2. The Fully-Developed Disease. 3. Co?na. There 
may be some Prodroities. The child is irritable, has a headache, and is 
listless. Unless the Headache is very constant, there is nothing definite. 
Children do not often have headache. When they complain of it day after 
day it is very alarming. It may be Local or General. It may wake the 
child from its sleep, with a Cry which is so peculiarly shrill that it has been 
designated the Meningeal or Hydro-Cephalic Cry. Fever ensues — at first 
slight; then the temperature may run up to 103 F. and 104 F. The 
Pulse is small and tense. The Special Senses are very acute. The 
child wants the room darkened. The noises of the street annoy him. 
There may be Wandering Delirium or simply Insomnia. This lasts 
three or four days, then the Fully-Developed Stage is reached. This is 
marked by Flushing of the Face and local Sweating about the 
head. At times there may be Convulsions or spasmodic twitching. 
There is a tendency to Delirium and to starting out of sleep with a cry. 
The Headache persists, the Pulse continues frequent, but may present 
little halting in its character. There is Vomiting without nausea, which is 
strictly Reflex in its character. Constipation is marked. The Belly is 
sunken and scaphoid. The Ilia and Ribs stand out. There is apparently 
no room for the intestines. It will now be noticed that if the finger is drawn 
over the brow or the skin of the face a red streak or Cerebral Tache will 
result. If the eye is examined there will be found Optic Neuritis and 
Cerebral Tubercles. The Pulse now becomes slow. It falls from 120 to 



10 

90, to 70, or even 60. This with fever in a child is very important. Squint 
may now develop. The child lapses into a state of Coma ; the Pulse becomes 
irregular and often increases beyond the power of counting ; Breathing be- 
comes of the Cheyne-Stokes type. There are still local Sweats and Cerebral 
taches, Flushed cheeks, Local spasms, Squint or occasionally General Convulsive 
Movements. The child wastes rapidly, Vomiting stops, Constipation continues, 
swallowing becomes difficult and Death ensues from paralysis of nerve-centres 
and Inanition. The case may last twenty-eight days, but fourteen or fifteen 
is the average duration. 

Diagnosis. There are few diseases with which this can be confounded. 
1. It may be mistaken for Typhoid Fever. Typhoid is often anomalous in 
children, and is wanting in nose-bleed, diarrhoea and what we regard as its 
characteristic temperature. It is often not fully developed in children. If 
tubercles have attacked the membrane of the bowels, Meningitis is very 
liable to be mistaken for Typhoid, for then the belly is distended instead 
of being scaphoid, and there is diarrhoea instead of constipation. We 
can easily distinguish Meningitis from Typhoid by the change in the 
Optic Nerve. The course of the fever is more characteristic in Typhoid. 
There we have no squint, no local palsy, no tendency to local spasm, and 
the peculiar halting pulse does not appear. At the end of four days there 
should be no doubt as regards the diagnosis. 2. The question may come 
up to distinguish it from Si?nple Meningitis. Here we would be guided by 
the existence of a hereditary tendency and predisposition, the occurrence 
of a similar case in brothers and sisters as they reached the same period, the 
existence of tuberculous formation elsewhere, tenderness of the spleen and 
enlargement of the lymphatic glands, and by the results of Ophthalmoscopic 
examination of the Retina. 

Prognosis. As long as you can cling to hope, do so. When you see 
advancing exudation and the approach of coma, you may inform the parents 
that the prognosis is utterly hopeless. All cases of recorded recovery have 
been where Idiopathic Lepto-Meningit'is has simulated the Tubercular variety. 

Treatment is purely palliative. The indications are to allay the fever 
by the use of a hot foot-bath and the application of ice to the head. We 
may give small doses of Aconite with Bromide of Potassium. This febrifuge 
and sedative treatment we pursue only to await results. The diet should be 
of the simplest kind ; light liquid food should be given and the bowels gently 
moved by an Enema or simply by laxative food. No purgatives should be 
ordered ; the chance of it being Typhoid fever should warn us against them.. 
When the true nature of the disease is seen, continue the light diet as the 
child is willing to take nourishment. Keep up the Bromides to control spasm. 
Treat the case as though it might be Simple Meningitis. Give Iodide of 
Potassium from the first in positive doses, but still graduated to the age of the 
child. For a child of two years old give one-half grain every two hours,, 
increased to one or two grains ; this would be equivalent to ten grains in 
an adult, and would do as much good as any amount in a non-syphilitic case. 
With the Iodide we may combine Fluid Extract of Ergot, giving of the latter 
three, four or five drops to a child of two years, making in a day one-quarter 
to one drachm of the extract. Blisters are of doubtful utility; if the evi- 
dences of inflammation are high and there is great pain, we may apply one 
to the mastoid region of the scalp, but not to the nape of the neck, as has 
been recommended. 

II. Idiopathic Meningitis occurs most commonly in children. The 
ordinary Causes are : 1. Atmospheric Disturbances. Sudden changes 
of temperature have been known to produce it. 2. It may occur as a 



13 

Secondary Complication in Pneumonia, Typhoid Fever, Erysipelas and 
Rheumatism. The Symptoms of Meningitis when arising in these dis- 
eases is puzzling, especially because we have marked brain symptoms from 
other causes, as, e. g., from Pyrexia, and we may hesitate as to whether there 
is any actual organic affection of the brain or not. If, without intense Pyrexia, 
we have — i. Acuity of the special senses. 2. Headache. 3. Flushings of 
the head and face. 4. A disposition to muscular spasm, tremor or actual 
convulsions. 5. Squint or other local palsy. 6. Neuritis of the optic nerve. 
7. The Pulse halting, rapid, then slow and irregular, we know we have a 
Meningitis. 

Prognosis. It is very fatal, but not inevitably so, except in the tubercu- 
lar form. We may have recovery with impairment of some member. 

Treatment. Absolute rest in bed. The exclusion of all light. The 
application of cold to the head and of a blister or mustard plaster to the 
calves of the legs and soles of the feet. We must use sedatives, as Bromide 
of Potassium and sometimes Opiates to relieve pain. Ergot is useful com- 
bined with Iodide of Potassium in proper doses. If life is preserved, as the 
disease passes through the acute stage, we may omit Ergot, and put in Bi- 
chloride of Mercury to absorb the exuded lymph. A light unstimulating diet 
should be given throughout. 

Chronic Cerebral Meningitis is most commonly met with as an ac- 
companiment of injury to the bone, as the result of Syphilis, or as a result of 
Tumor. Its diagnosis is often obscure. 

The Symptoms are localized pain referred to nearly the spot of inflam- 
mation. Evidences of irritation of the surface of the brain as shown by 
Insomnia or disturbed sleep. Subjective sounds. Disordered 
vision. Sometimes a little giddiness of gait and then evidences of 
irritation or of pressure on the nerve trunks going from the brain centres, 
so that we may have creeping sensations in the auditory or optic nerves 
or in the motor nerves of the eye-ball. There is a loss of flesh and 
general ill health. 

Diagnosis. The greatest difficulty consists in distinguishing it from tu- 
mor of the brain; this can only be decided by the result of treatment. It 
may arise from rheumatism. If Syphilis is present elsewhere this may put 
us on the right track. If it came on with an injury it may have hurt the 
Dura and then spread to the interior membranes. 

The Prognosis depends on the exact cause and duration. It is most favor- 
able in Syphilis. It is hopeless in the case of Tumor or an affection of the 
bone. 

Treatment. It may be cured by local counter irritation — the use of the 
Cautery applied as near as possible to the seat of pain every eight or ten 
days. If it is a syphilitic accompaniment Iodide of Potassium is indicated 
associated with a Mercurial Salt. 

Cerebro-Spinal Meningitis is chiefly met with in constitutional 
conditions. Frequently spotted fever is characterized by inflammation of 
the spinal chord. 

Spinal Meningitis is considered under the three divisions of: 1. 
Pachymeningitis. 2. Lepto-Meningitis ; and 3. Arachno-Meningitis or 
Arachnitis. As in the brain, Spinal Pachymeningitis is associated with 
Fracture, Caries, Wounds and the like. 

More interesting is Spinal Lepto-Meningitis, i. e., inflammation of 
the Pia Mater of the chord, which sometimes spreads and becomes basic. 

Causes. 1. Rheumatism. 2. Exposure to atmospheric changes. 3. It 
may follow shock or concussion. 



14 

The Symptoms are: i. Pain in the back, aggravated by motion. 
2. Pain radiating from the spine round the sides and down the arms and 
legs. These are very marked. 3. Muscular Hypersesthesia. 4. Increased 
Reflex Irritability. 5. Limited breathing. 6. Retention of urine. 
7. Constipation. 8. The Pulse is frequent and we have fever. If it 
creeps up and involves the base we have an implication of the brain and of 
the nerves coming from it, and hence we should have symptoms of Cerebro- 
spinal Meningitis. 

Diagnosis. We might confound Spinal Meningitis with — 1. Acute Rheu- 
matism, but there we have stiffness of the joints. In children, however, inflam- 
mation of the joints may be absent. In rheumatism we do not have Reten- 
tion of the urine. There is not so much Pain nor so much Hyperesthesia, 
but there is a copious acid sweat. The urine is intensely acid, and there is 
more Fever than in Spinal Meningitis. We should remember, however, that 
Rheumatism may be complicated with Spinal Meningitis. 2. With Teta- 
nus. Tetanus however generally follows a Traumatic cause, and is associ- 
ated with Tonic Spasm and Contraction of the Buccinators, causing Lock-jaw, 
and gradually spreading lower down. Tetanus developes more gradually. 
There is not so much fever. The bladder is not so apt to be affected. 

The Course of acute Spinal Meningitis is irregular. It usually lasts from 
ten to fourteen days. 

The Prognosis is doubtful. If it is limited to the chord it is favorable. 
It is apt, however, to leave thickening of the chord. If it creeps up and de- 
velopes Basic or Basilar Meningitis it may terminate fatally. 

The Treatment should be on the same plan as that adopted in Idiopathic 
Cerebro-Spinal Meningitis. 1. Leeching and cupping along the chord 
where the girdle pains indicate intensity of inflammation. 2. Internally, 
give Quinia, Opium, Ergot, Belladonna and Iodide of Potassium. Quinia is 
useful in lessening the exudation by its influence on the crasis of the blood 
vessels. Full doses should be given. Opium is essential for subduing irri- 
tability of the system and promoting quiet sleep. Ergot is beneficial for its 
special action on the vessels of the chord, and for absorption of such exuda- 
tion as may occur. Give three to ten grains of Quinia twice daily, and give 
Opium per rectum or hypodermically. Apply liniments over the track of 
the painful spinal nerves and along the spine. This affection is more com- 
mon than is generally believed. Tumors of the spinal chord are rare. 

The food for a patient suffering from Spinal Meningitis should be light 
and simple. 

Hydrocephalus. The expression acute hydrocephalus was formerly em- 
ployed to designate Tubercular Meningitis, because there is an effusion into 
the ventricles of the brain. The presence of effusion into the ventricles is, 
however, a purely accidental concomitant. There are two kinds of hydro- 
cephalus: 1. External, or meningeal 2. Internal, or ventricular. In 
the one the effusion lies between the brain and the skull ; in the other the 
brain is distended, its substance thinned out, and the ventricles filled with 
the effusion. The external form of the disease is rare, but is sometimes 
produced by a meningeal hemorrhage which sets up slight meningitis. 

The brain does not develop properly. The condition may come from the 
transformation of a meningeal clot, or, because the effusion breaks through 
the Corpus Callosum. The Internal is the more common form of hydro- 
cephalus. In the internal form the ventricles are greatly distended. The 
Serum comes from an inflammation of the lining membrane of the Ventricles 
or from pressure on the veins of Galen. As the effusion increases it spreads 
out the substance of the brain. The furrows in the brain disappear and the 



17 

convolutions are flattened. The bony case grows in proportion to the dis- 
tension ; the vault of the cranium is increased in size ; the Fontanelles are 
increased in area ; and the Sutures become very wide. New centres of ossifi- 
cation appear in the wide sutures. This development brings about a strange 
disproportion between the head and face. The orbit is very flat and is 
pushed from the horizontal to the oblique position. The cranium is very 
voluminous. Various parts of the brain may be imperfectly developed ; 
some centres of the brain may be wanting, or, we may have occlusion of one 
of the veins. 

Causes. Hydrocephalus is a disease of infancy. It may begin before 
or soon after birth. It may begin the second year of life or as late as the 
seventh year. Infancy, then, is a strong predisposing cause. The disease 
may come from an injury to the mother during gestation. But it may 
come from inflammation set up by a tumor. There are cases in which 
the disease is brought about by causes which we are not able to detect. 

Symptoms. First, the head of the child is noticed to be growing to 
a larger size than is usual, while the child may apparently be in perfect 
health. Secondly, as the disease advances there may be feverish spells 
with heated head, disturbed sleep, sudden cries, and in forty-eight hours 
these symptoms subside and the child appears to be all right again. Often 
the tongue is coated. The head gets bigger by spells. The axes of the 
eyes are directed downward. The child cannot walk well, the head 
falls to one side, or the child sits or reclines constantly. The functions of 
the brain do not develop, and the child is often dull. The special senses 
are impaired, or the child may keep up with other children in its lessons at 
school ; the head alone may indicate the trouble. 

Prognosis. The duration of this disease is very variable. Some children 
are hurried off by convulsions, especially where tumor is present. Others 
may be carried oft by Bronchitis from injury to the Pneumo-Gastric Centre. 
Nutrition may fail. Diarrhoea sets in and can't be checked. In some cases 
the children regain the power of walking, and the muscles develop. Cases 
are on record of patients living to be thirty, the head containing gallons of 
water, but thi's is rare. 

Diagnosis. We should never express our suspicion of the existence of 
this condition until we are perfectly sure. It may be confounded with 
simply an abnormally large head. In Rickets a big head is one of the 
morbid conditions. The Rickety skull is square and chunky, showing 
persistent thickening. Changes in the wrists, ankles, etc., are indicative of 
Rickets. The peculiar feverish spells and the interference with the mental 
functions make the Diagnosis easy. The Rickety skull again is entirely 
■different in appearance. 

The Treatment of Hydrocephalus is very unsatisfactory. The Lesion is 
incurable, but we should resort to all the means within our power as though 
the Lesion were curable. Adhesive strips of plaster should be applied round 
the head so as to exert a uniform pressure. These should be loosened if 
brain symptoms come on. But even this is unavailable. Prolonged use of 
Mercurials, Iodine, and of the Iodides has proved futile. If the child's 
functions are good, and we think it is an inflammation of the membranes, 
we simply put him on the use of alteratives to absorb effusions. We can 
treat special symptoms as they arise. We combat feverish symptoms with 
Opium, Aconite and Quinine, Digitalis and simple Febrifuges. Wheeled 
crutches, such as are made in Newark, are very useful. To them is attached 
a jury mast, so as to keep the head erect, and treadles to work the wheels. 
By means of this a child may develop strength for a time. The idea may 



i8 

occur to let the fluid out. This is useless in the internal form. Where the 
water is between the brain and its membranes it is useful. A pint may be 
drawn off, and complete recovery take place. Where the accumulation is 
inside the Ventricles the conditions which give rise to it are such that mere 
operation would not remove them. 
Affections of the Cerebrum: 

Anaemia, 

Congestion, 

Thrombosis, 

Embolism, 

Softening, 

Hemorrhage, 

Apoplexy. 
The connection between the above is not so close in theory as it is seen to 
be in practice. 

Anaemia implies a diminution of blood in the cerebral mass. It may be 
due to obstruction in any part of the arteries or to enfeebled power of the 
heart. The chief cause of obstruction is Atheroma accompanied by a thick- 
ening of the walls and a diminution of the blood supply. We have either 
a depressed function of the whole brain or of only the part which is anaemic. 
The Symptoms are Vertigo, a tendency to syncope on sudden exertion, 
and impairment of the Intellectual powers, memory, perception, and 
the like, and of the special senses. When the anaemia is intense and 
prolonged, the nutrition of the brain suffers and softening may be induced, 
especially if the disease of the vessels is extreme. We may have Rupture and 
Apoplexy. Thus we have a pathological chain from Anaemia to Apoplexy. 
Cerebral Congestion is that state in which there is an excess of blood 
in a part or in the whole of the brain. It is an undue fullness of the vessels 
of the brain. This may be active and then there is arterial blood from 
hypertrophy of the heart, but more commonly it is passive and is due to an 
undue accumulation of venous blood. We meet this frequently and in 
intense degrees. Causes. It is produced by anything which prevents the 
return of venous blood into the chest, e.g., wearing tight collars. A state 
of Plethora with a feeble heart which allows the blood to accumulate in the 
Sinuses. Pressure of a tumor on a vein. Passive Congestion is a common 
occurrence. Sometimes it is Acute and sometimes Chronic or Persistent. 
The acute form occurs in those who have a predisposition. A man with, 
plethora and a weak heart gorges himself with strong food and then under- 
goes exertion, Acute Congestion results. There is fullness and dull pain in 
the head, confusion of mind, or full unconsciousness with stertorous breathing. 
The face is flushed. The veins of the face are distended. The Pulse is full. 
The heart's action and the breathing is labored. The patient feels numbness 
and loss of power in the arms and legs, which may be hemiplegic or only 
affect one limb. If he has been unconscious, when he comes out he finds 
weakness of the part not amounting to actual palsy. There is very little use 
of Temperature. Attacks may last three or four days or three or four hours, 
and if there is no rupture of the blood-vessels the patient comes out and gets 
well because there is no lesion. It is impossible to draw the line between 
acute congestion and slight hemorrhage. Chronic Congestion is a continual 
fullness of the vessels of the head. The patient suffers from obtusive head- 
aches, is restless, sleep is disturbed with dreams. He feels oppressed when 
he lies down and is better when he sleeps semi -recumbent. There is confu- 
sion of mind. Changes of temper are noticed. The patient is irritable, 
is easily tired. The secretions are disturbed. Congestion of the stomach 



21 

and Liver may exist too. A sudden increase of pressure may give rise to 
Apoplexy. Nutrition may be interfered with. Softening may result, and 
from it may spring Hemorrhage. 

Thrombosis is coagulation of blood in a vein, artery or sinus. It is 
connected with changes in the walls of the vessels or Atheroma. Cerebral 
Embolism is the plugging of an artery in the brain by a clot driven from 
a distance. This may have come from the heart, or may have gathered on 
the rough lining of Atheroma. Its size, if large, will often stop it at the 
Circle of Willis. If small, it may get into the small vessels. If it stops at 
the Circle of Willis it will not cause Softening, because the anastomosis is so 
complete. If it is very small it will not cause Softening, because the other 
vessels supply the place of the vessel which is plugged. 

Cerebral Softening is a very common and important condition. It is 
a loss of consistency of some portion of the cerebral substance, owing to 
interference with its circulation. Anaemia is a long step on the road to 
softening. Atheroma, or acute obstruction, may so hinder the passage of 
blood through the Common Carotid or the Innominate, that we have impaired 
circulation and malnutrition of the part. Long-continued Anaemia or Con- 
gestion, continued over-taxing of the brain, exhausting its vitality, impairing 
its nutrition and producing Anaemia, finally causes softening. We find it 
in the neighborhood of a tumor, or around local meningitis. Anatomically, 
the softened part is whiter than the surrounding matter. It varies from a 
cream-like liquid to a barely perceptible softening. If we examine it micro- 
scopically, we find the nerve fibres broken, and globules escape something 
like oil drops and compound granular cells. The extent of the softening 
varies from a very minute point to a whole hemisphere. 

Symptoms of softening are very varied, according to the part affected and 
its extent. W T e notice a failure of motor power, though the patient may 
be very restless. His gait grows shambling. He trips. He does not lift his 
feet and put them down regularly. Sometimes we have staggering, and 
Vertigo. Intellectual Changes take place. Memory fails. There is often 
a change of disposition. He becomes restless, peevish, irritable and even 
quarrelsome. In later stages we find a complete perversion of the moral 
nature. There be total depravity. With this we have changes of other 
functions. The appetite is often capricious and voracious. The patient 
bolts his food. The circulation is weak. The pulse small. The bowels 
costive. The flesh may be well maintained, but grows soft and flabby. In 
this condition the patient is carried off by apoplexy. Acute congestive 
attacks make the patient feel worse, and then he may get better ; but the 
disease has advanced. It may last three, five, or even ten years. The 
patient becomes childish, and is carried off by some accident or by hemorr- 
hage. The Prognosis is altogether unfavorable. The disease advances 
slowly, and terminates fatally. 

Apoplexy is a rupture of a vessel within the cranium, attended with 
hemorrhage into or upon the cerebral mass. It may be Meningeal, i. e., 
when the apoplexy is on the membranes; or Cei'ebral, i. <?., in the brain sub- 
stance. There may be one or more spots of hemorrhage. It varies in 
extent. Thus, we may have mere Ecchymosis, i. e., Capillary hemorrhage, 
or the hemorrhage may burst into a ventricle and tear the surrounding brain 
substance to pieces. 

Among the Causes of Apoplexy are: — i. Plethora and whatever 
contributes to the habitual fullness of the blood vessels of the brain, e. g., 
increased propulsive power of the heart, as in simple hypertrophy, particu- 
larly if the vessels are weakened, as in the interstitial form of Bright's 



22 

Disease. In fact, it is very common in Bright's Disease. 2. Whatever 
lessens the consistency of the brain, 1. e., Whatever favors Softening. 
3. Atheromatous changes, leading first to Softening and subsequently to 
Apoplexy. 4. Age exerts an important influence. It is most common in 
advanced age. Next in infancy and early childhood, when the vessels are 
brittle or weak. 5. Sex. It is more common in males than females. The 
former are more exposed to its causes. They have Syphilis and Bright's 
Disease of the Kidney more frequently. 6. Their Occupations expose 
them more to violent exercise. The proportion of cases among men and 
women is as three to one. 7. Certain Habits, as gluttony, drunkenness 
and sloth, predispose to Apoplexy. Persons with short necks used to be 
called apoplectic. Such people are generally quick-tempered and sensuous, 
but there is nothing in their anatomical structure to justify this opinion. 
Inherited Gouty Diathesis may predispose to high living, and this to 
Apoplexy. 

The Morbid Anatomy is very interesting. When the hemorrhage is 
recent the blood is dark, the surrounding brain substance stained and more 
or less infiltrated. The hemorrhage may be in a sack, with brain substance 
•quite healthy around it. If, however, Softening has occurred, the brain 
may be a good deal broken up. In time the clot undergoes contraction, and 
its coloring matter crystallizes in rhomboidal crystal of Haematin. Inflam- 
mation occurs in the intercellular substance around it, and makes a cyst wall. 
Years after we may find a little cavity containing pure serum and the most 
beautiful crystals. Sometimes we merely see a cicatrix and a few crystals 
to mark the spot. 

Seats. Most frequently it occurs in the neighborhood of the Corpus 
Striatum through which the motor fibres pass. About one-half of all cases 
of Apoplexy occur here. The Pons Varolii, Peduncles of the Cerebrum and 
Cerebellum, the Cortex and the Ventricles are the most frequent seats. 
Attacks of Apoplexy may be divided into the three grades of Slight, 
Marked and Fatal. The Symptoms of Slight Apoplexy are simply 
those of congestion. It may be difficult at times to say whether there has 
been a loss of blood or not, it may be so slight. At other times we can say 
there has been a small escape. The attack may be attended with or without 
unconsciousness. The Symptoms are fullness of the head, distress and 
slight giddiness. The patient often vomits. There is a feeling of numbness, 
tingling and weakness in the arm and leg of one side, and more or less loss 
of power in that side. It may be very transient, passing away in a few hours, 
or there remains a partial weakness of that side. Under these circumstances 
it would be difficult to say if there had been a rupture. We may have 
weakness of the side and then a kind of hemiplegia according as the inter- 
ruption offered to the motor current by the clot is longer or more persistent. 
When the brain is ill nourished and has undergone some softening, it is 
wonderful how the consciousness is unaffected, and the paralysis is only seen 
the next day. The hemorrhage is apt to be unassociated with unconsciousness 
and grave symptoms of the moment. But very often the first attack is a 
slight one of this kind, and the patient dreads the recurrence of similar 
attacks. 

Marked Apoplexy comes on rather suddenly. There may be prodromes 
of Headache, but generally the patient falls without warning as if struck 
down. Unconsciousness may be partial or profound. The patient is seized 
with a fit as in epilepsy. Vomiting is not so common as in a simple attack. 
The pulse is full and heavy. The breathing labored, the face flushed. 
Sometimes, and particularly if the patient's brain has been anaemic, the face 



25 

is pale, and the pulse weak. Symptoms of turgescence are wanting. The 
Temperature is at first depressed but soon rises above the normal and may 
run very high. We notice symptoms of Palsy. There is often turning of 
the head and eyes toward the injured side of the brain. This phenomenon 
is known as "conjugate deviation," and is of assistance in diagnosis. The 
muscles of the Face are palsied. The cheek flaps in respiration, and, as the 
muscles of the other side retain their power, the face is drawn to the injured 
side. The Paralysis extends to one side of the body involving the arms and 
leg. This is noticed even when the patient is unconscious. This apoplectic 
condition lasts a varied time, from one-half an hour or an hour to several 
days. The arm if lifted falls as dead j whereas the arm on the unaffected 
side falls in the normal manner. 

The third and gravest variety is where there is a drowning effusion which 
is very extensive. The onset is a Convulsion. The whole muscular system 
is profoundly relaxed. The pupils are dilated. The breathing stertorous,, 
with purling cheeks. The pulse grows rapidly small. The lungs fill up with 
serous effusion. The heart fails and death follows in a few hours or a few 
days. 

SYMPTOMS REMAINING AFTER RECOVERY. 

If we consider the state in which we find a person who has recovered from 
an attack in the first place as to Palsy, we give the name of Hemiplegia to 
the paralysis which follows cerebral hemorrhage. This is on the side of the 
body opposite to that of hemorrhage. The crossing of the fibres at the 
peduncle explains why the paralysis is on the opposite side. Some fibres,, 
as those which furnish the Orbicularis and Frontalis, arise in such a way 
that a single hemorrhage does not affect them. Note the difference between 
this palsy and that of the Facial nerve. The patient has a hemiplegic gait, 
and drags his leg by means of the rotators of the tnigh. He walks with his 
arm in a sling. The muscles of the arm often remain paralyzed longer than 
those of the leg. Certain changes take place in the condition of these mus- 
cles. We have an early rigidity due to an inflammation around the fibres. 
Sometimes this contraction does not come on at once, but it is only after 
some time that the muscles begin to contract. Early rigidity may pass away. 
Late rigidity remains. The muscles waste but do not undergo much degen- 
eration. It is a simple atrophy. The electrical condition of the muscles may 
be increased, but this soon subsides and then their electrical irritability dimin- 
ishes. The circulation also is often affected. The return of power is usually 
only partial. A patient may regain almost complete use of his limbs, but this 
is rare. The Mental Condition is very varied. We often have Memory, Will 
and Energy impaired. Not rarely do we have that depression of spirit and 
alteration in character which is associated with softening, and when softening 
does not precede the hemorrhage it may be brought on by the latter. There 
is always danger of a second attack, and the patient lives in constant dread 
of its occurrence. The Special Senses may or may not be impaired. The 
function of articulate speech is frequently lost, and we have as the result 
Aphasia,. It has been found that the Centre which governs articulate speech 
lies perhaps on both sides of the brain, but the active centre is on the left. 
It is situated in the Island of Reil, which lies within the Fissure of Sylvius. 
Aphasia is an extremely important symptom. It is not connected with palsy 
of the tongue. The tongue is paralyzed on the same side as the arm and 
face. The tongue is stuck out towards the paralyzed side owing to loss of 
opposition. The paralysis soon passes away, but Aphasia may last for life. 
This is a "Loss of Words." The patient struggles to get the right word, 



26 

and may burst into tears from inability to remember the right name of some 
familiar object. He may remember the word and write it down in a good 
hand, but is unable to co-ordinate memory and the muscles of articulate 
speech. Aphasia of course affects the patient's legal status. He cannot com- 
municate his wishes, as, e.g., by making a will. The General Health may 
be good. It is affected by the causes which brought about the first attack. 
A patient may have several attacks. The popular notion is that the third 
kills. Death usually occurs from progressive softening of the brain. 

Diagnosis. I. We may confound a slight attack with Congestion. We 
should be on our guard against a positive expression of our opinion, as we 
cannot always tell. Even when paralysis is very brief we must be guarded 
against an assertion that there has been no hemorrhage. Examine the con- 
dition of the teeth. The want of supporting teeth may give rise to the 
appearance of an apoplectic face. 2. Slight attacks should be distinguished 
from Embolism. This, too, causes a sudden attack. Unconsciousness is not 
usually complete. There may be a local source from which the attack has 
come if the patient has heart disease ; but a patient with heart disease may 
also have apoplexy. Sometimes the examination of the Retina proves that a 
bit of fibrin has plugged one of its vessels, and this would be an index of the 
embolic nature of the case. 3. We should be very careful to distinguish 
Apoplexy from Drunkenness. Many a man has been taken to jail with Apo- 
plexy. The odor of the breath and history of the circumstances are diag- 
nostic. 4. In Epilepsy the convulsion is more frequently one-sided, but 
when the convulsion has ceased we may have paralysis of one side. In 
Epilepsy there is no paralysis. 

Prognosis of Apoplexy is difficult. While unconsciousness lasts we 
should never venture an opinion. After the attack has passed over, we must 
consider the patient's liability to other attacks. This will be in proportion 
to the disease of the blood vessels and to. softening of the brain. We next 
consider the prospect of the recovery of the use of the paralyzed limbs. In 
this we are aided by the promptness with which power is regained, by the 
absence of wasting, and decrease in rigidity, and by the changes in the 
nutrition of the part. The maintenance of electrical irritability is favorable. 
The Treatment of Apoplexy is divided into three parts — 1. Prophylactic. 
2. Treatment of Convulsion. 3. Treatment of Sequelse. The first is the 
most important. If patients would listen to physicians, there would be less 
apoplexy. A strict course of regimen to reduce plethora, and bring about a 
uniform circulation, will avert the danger and ward off hemorrhage. Work 
must be restricted, and excitement and everything likely to disturb the 
temper must be avoided. The dress should be so arranged as not to restrict 
the vessels of the neck. The patient should eat slowly, and avoid the heat 
of the sun. In cases of constitutional syphilis, we should put our patients 
on their guard against apoplexy by informing them that, though all external 
manifestations may have ceased, insidious changes will for years goon in the 
blood vessels, hence Anti-syphilitic Treatment should be kept up for a month 
or two annually for twelve, fifteen, or even twenty years. Treatment of 
Seizure is governed by the nature of the attack. If the face is flushed, the 
pulse full, the eye congested and the vessels beating, whether you think there 
is Congestion or not, bleed the patient. What is to be feared is surround- 
ing congestion of the brain The hemorrhage has not sufficiently relieved 
it,"and the patient may be seized in a few days with another attack. Bleed 
once to a moderate degree, and don't repeat it. In mild apoplexy no one 
would think of opening a vein. We may put cold to the head, by means of 
a flow of very cold water through a rubber tube coiled round the head, or 



2 9 

by an ice-bag. The patient must be kept in a cool room, in bed with his 
shoulders raised, and warm applications to his feet. Give him nothing to 
swallow. If his pulse fails, give a hypodermic of brandy, with or without 
digitalis and ether, and enemata. The brain must have perfect rest and 
quiet for a considerable time. For months we must have complete brain 
rest. Change of scene and travelling are good. The patient should not, if 
practicable, return to his old haunts. Subsequent treatment depends on 
the causes which led to the attack and to their removal. Hygiene, so as to 
give the nervous system tranquility. Very cautious dieting. In treatment of 
paralysis, we favor the absorption of the clot by Iodide of Potassium and 
small doses of Mercury. When all evidences of irritation have subsided, 
we may cautiously increase the motor functions with Strychnia. We will 
use nutrients and tonics, as cod liver oil, hypophosphites and bitter tonics. 
We must manipulate the paralyzed part to prevent contraction, wasting and 
stiffness of the joints. Douches, either hot or cold, or alternately so, may 
be tried, and stimulating liniments. Electricity, in the form of the Faradic 
current, applied to the various groups of muscles to maintain their nutrition. 
This treatment must be pursued for a long time. 



ORGANIC CONDITIONS OF THE SPINAL CORD. 

I. Meningitis. 

II. Congestion. 

III. Inflammation or Myelitis 

Closely connected with this are — 

i. Thrombosis, 

2. Embolism, 

3. Hemorrhage, 

4. Softening, 

which may all be considered under this general head. 

IV. Sclerosis. 1. Lateral. 2. Posterior. 3. Disseminated. 

V. Affections of the Gray Matter and Cells, often called Anterior 
Poliomyelitis, which includes: 1. Infantile Palsy. 2. Atrophic Spinal 
Paralysis of Adults. 

VI. Morbid Growths. 

The above are the morbid lesions that we think of in connection with the 
spinal cord. 

Myelitis. Opinions differ as to its frequency. Some observers regard 
a great many organic affections as coming from the cord ; others, degenera- 
tion, as Sclerosis, softening as an atrophy, and breaking down from want of 
nutrition. Inflammation plays a considerable part. If in a case we are apt 
to find associated the evidences of Myelitis and obliteration of the blood- 
vessels, some effusion of blood, and, as the result of interference with nutri- 
tion, softening, we find a little cord of yellow matter and evidences of 
hemorrhage, hsematin crystals and the like ; and around this softening, we 
may reason in either direction to embrace Softening, Thrombosis, Embolism 
or Inflammation. Some cases come on so gradually that they appear to be 
the result of softening. Others come on so suddenly that hemorrhage may 
have started them. 

Myelitis and Softening. The Morbid Anatomy differs in its seat. It 
may be high or low, Cervical, Dorsal or Lumbar. Sometimes it is limited 
to not more than one-half an inch ; sometimes six to eight inches will be 



( Acute. 
[ Chronic. 



30 

involved. The cross-section of the cord is differently affected ; it may affect 
the whole section or only one-half, or the outside, or only the central part. 
The symptoms vary in these different cases. 

The Causes are: i. Traumatic. 2. It may be excited by a Thrombus 
or a Clot. 3. It may be produced by the action of cold on a system ex- 
hausted by overwork, Venereal excess and the like. 4. Some Acute Dis- 
eases, as Typhoid Fever and Pneumonia, leave an exhausted state of the 
spinal cord, after which Myelitis occurs. 

The Symptoms are: 1. Pain in the back, rather dull, radiating into 
the limbs or also into the arms, according to the level of the lesion. 2. 
Numbness and Tingling of the Extremities. 3. Moderate Fever and 
acceleration of the pulse. 4. Palsy below the level of the inflammation. 
Hence Cervical causes Paralysis of the whole body. Dorsal would give rise 
to Paraplegia. 5. The Bladder and Rectum are Palsied. Sometimes we 
have Incontinence and Dribbling, and sometimes Retention both of urine 
and feces. 6. There is a marked tendency to Bed Sores, which form with 
great rapidity, attended sometimes with sloughing of the whole derm over 
the Sacrum, which is usually symmetrical, but where the lesion is worse 
on one side, the Bed Sore is worse on that side. 7. Girdle Sensation 
is often complained of. 8. Electro-Muscular Irritability is retained. 
The muscles respond to the Electric or Galvanic current. 9. Reflexes 
are diminished, and may be lost in a short time. 10. A moderate amount 
of Wasting from mal-nutrition and disuse, but there is not such marked 
atrophy as when the anterior columns of the gray matter are affected. 

These symptoms may develop quickly so that in a few days the whole 
condition with Bed Sores is developed. At other times they may come on 
so slowly as to suggest that it is rather a process of softening. It appears 
in an acute and subacute form, and is apt to become chronic. In a great 
many cases Chronic Paraplegia and affections of the rectum and bladder are 
associated with Chronic Myelitis. 

The Diagnosis is, of course, easy. It is difficult to mistake it for any- 
thing else. We must not be misled by hysteria. There are cases of Paraplegia 
which are merely functional, as after diphtheria, but there has been no true 
myelitis set up. 

The Prognosis is always anxious, and yet we must be careful not to make 
it too doubtful. An Acute case may completely recover. More often Sequels, 
for example, Palsy, may be left behind. More frequently it runs into a 
chronic form. We must be influenced by — 1. The degree of Palsy. 2. The 
way in which the muscles retain their tone. 3. The condition of the rectum 
and bladder. 4. The presence or absence of bed-sores. Eight or ten days 
is the usual duration of the case. 

Treatment involves — 1. Absolute rest in bed. 2. The avoidance of the 
development of Bed Sores. From the first moment place the patient on a 
water-bed. Shift his position every little while. Insist upon scrupulous 
cleanliness. Every appearance of redness must be treated at once with cover- 
ing, and soothing medicine. The use of the catheter is imperative. There 
is great danger of Cystitis, but infinitely more so when we use the catheter 
in medicine than in connection with surgical operations. Cystitis is so 
dangerous a complication that chemical cleanliness must be insisted upon. 
Care, too, is needed in reference to the bowels. Sometimes they must be 
moved by an enema. Anticipate dribbling by suitable measures and watch 
closely for the appearance of Bed-Sores. Internally, use Opium according 
to the needs of the case to secure rest and remove pain. Give Quinine gr. 
xii to xvi, with Potassium Iodide and Ergot in doses adapted to the age, 



33 

weight, and tolerance of the patient. In many cases it is a question of 
nutrition, and we must sometimes stop Iodide of Potassium and Ergot and 
depend on the nursing and feeding. A patient may thus recover more spinal 
power than at first seemed possible. 

Hemorrhage of the Spinal Chord. The causes are sometimes Trau- 
matic, e. g. y Violent Concussion, a fall from a height, or blow upon the 
spine. As Myelitis may arise from Hemorrhage, so Hemorrhage may result 
from Myelitis. We may have a slowly forming tumor, and around it there 
will suddenly take place a Hemorrhage. It may occur as a Primary- 
Trouble, where the blood vessels are diseased, brittle and rotten. 
Anatomical Changes. If it is fresh, we find a clot imbedded in the 
substance of the chord, tearing it up. It contracts and becomes paler. 
Finally it tends to a little depression, and has a cicatricial appearance, and 
we have a patch stained with Hsematin. All around this Softening is set up 
precisely as in hemorrhage of the brain. 

Symptoms. Sudden onset with pain, and paralysis of motion, and 
sensation below the level of the hemorrhage. The Bladder and Rectum are 
involved. There is some tendency to Cystitis and Bed Sores. Reflexes 
are lost, and if the Hemorrhage has affected the grey columns, Muscular 
Atrophy may follow. 

Diagnosis. It is difficult to distinguish it from Acute Myelitis, except 
by the Traumatic nature of the cause, its abrupt appearance and the 
absence of Fever. 

The Treatment in the two diseases is similar. The same avoidance of 
bed sores, Opium to control pain, and the use of remedies to promote 
absorption of the clot kept up as long as may seem judicious. 

Anterior Polio- Myelitis or Atrophic Infantile Paralysis. For a long 
time the true lesion was not recognized. The Cause of the affection appears 
to be — i. Some Predisposition on the part of the child. 2. The Action 
of Damp. A child sits on a cold step, is put to bed apparently well, and 
next day the disease develops. 

The morbid lesion is Inflammation of the Anterior Roots of the 
Gray Matter. This leads to degeneration of the Nerve Cells. In a large 
section of the Spinal Chord we find in the anterior horns large multipolar 
nerve cells, and both Physiology and Morbid Anatomy agree in saying that 
on their integrity, nutrition of the muscles depends. When these waste, 
the muscles in connection with them waste too. If in the neck, the 
muscles of the arm ; if Dorsal, those of the leg are affected. A single 
group of muscles, even an individual muscle, may be selected for wasting 
by the degeneration of these cells. In spite of everything the muscle goes 
on wasting till it is completely removed, so absolute is the connection and 
dependence of muscle nutrition on these Trophic cells in the Chord. 
This is what the name implies, and this is what clinical experience of 
Infantile Palsy describes. After this horn of gray matter has wasted we 
find the degeneration extending to the nerve roots, and then it is that the 
muscles waste. They not only waste but their fibres lose their Striation 
and undergo Granular Degeneration. 

The Symptoms are very characteristic, whether in a child or in an adult. 
It may be considered a Disease of Childhood, but is not confined to any age. 
The attack is eminently an acute one. A few hours only serve for the devel- 
opment of the Symptoms. 1. There is very little, if any, Pain. 2. Fever to 
a moderate Degree, 102 F. to 103 F., which only lasts two or three Days. 
3. The Pulse is somewhat accelerated. 4. The Paralysis may be complete 
and very extensive from the moment when the condition is detected. The 



34 

child is playing, is put to bed, and next morning Paralysis of one arm or leg is 
observed. The child is not entirely paralyzed, perhaps, but can with difficulty 
move the leg. The Paralysis is not extensive and very irregular, not a strict 
hemiplegia or paraplegia. Only a group of muscles may be affected. The 
child may be able to use the thigh, but not the flexors of the foot. In the 
course of a very few days the Paralysis begins to get better. Some of the 
parts affected improve, and the paralysis is circumscribed very often to a 
single member of a group of muscles. 5. We next notice that those muscles 
which are affected undergo permanent wasting. Atrophy sets in. The part 
is paler and cooler than it should be. Its power of responding to the Fara- 
dic current is diminished. An electrical reaction of degeneration sets in. 
A scrap of muscle when taken out by means of a small harpoon, shows loss 
of striation, atrophy and degeneration. These progress with considerable 
rapidity. During this time the general health is not much disturbed. The 
parts most commonly affected are the Flexors of the foot, the whole arm, 
leg, and spinal muscles. The Bladder and Rectum very rarely. 6. There 
is no tendency to Palsy of Sensation. Bed Sores are apt to appear. 
In an adult, of course, the Wasting is marked, but not to the same degree 
as in a child where the other member keeps on growing. This difference 
is very marked. '" Withered legs" are the remains of Infantile Atrophic 
Paralysis. Sometimes the other leg may attain to abnormal proportions from 
the child resting entirely on it. 7. When Infantile Paralysis affects a single 
muscle the opposing muscles act, and cause Deformity. The case then 
becomes one for Orthopcedic Surgery. 

The Diagnosis is very easy. No other disease presents anything like 
this picture. 

The Prognosis is altogether favorable as regards life. It may prove that 
some muscles may remain permanently palsied. As regards coinplete restora- 
tion of any group of muscles, or of a member, we should be guided by — 
1. The Slowness or Rapidity of the wasting. 2. By the absence or presence 
of Faradic Contractility; and 3. The fact of fatty degeneration having set in. 
To determine this we give an anaesthetic, and with a small harpoon take out 
a scrap of muscle. If it has undergone degeneration the case is hopeless. 

Treatment. We must use Counter-irritation at once. Time is import- 
ant. Apply Cups or Blisters to the spine. Enforce absolute Rest and the 
careful protection of the body from Draughts. Internally give Ergot and 
Belladonna at once in doses proportionate to age and tolerance. Keep the 
system under the influence of Quinine. The parts likely to be permanently 
paralyzed should be kept warm. We must have recourse to Frictions and 
Passive movements from a very early period, and as soon as Acute Symp- 
toms arise, use Electricity, either with a Slow interruption or the Galvanic 
Interruption. If Faradic Response is lost, go on with the Galvanic Current, 
and when response to this stops, go in for General Stimulation by general 
patting, by rubber bands or by manipulation. The leg may be put under a 
cupping-glass to keep it warm. The health must be carefully sustained, and 
nutritious diet given. Even in very bad cases Response to the Faradic Cur- 
rent may be restored, and the deathly pallor and coldness of the affected 
part is restored to the pink color and warmth of health. Treatment should 
be kept up persistently until we know that fatty degeneration has really set 
in. Then the case is hopeless. 

THE PERIPHERAL NERVES. 

Sufficient importance has not been attached to the study of affections of 
the peripheral nerves. Not only are they themselves liable to be diseased, 



37 

but their impairment may affect the centres. Especially is this the case in 
the Optic and Auditory nerves. These peripheral nerves are the chords 
through which motor impulses are carried from, and sensory impulses to, the 
brain, as well as the vaso-motor impulses. They are composed of nerve 
fibrils, with connective nerve tissue surrounding them, and enclosed in a 
good stout sheath. They are liable to inflammation, called Neuritis when it 
affects the central parts, and Perineuritis when it affects the sheaths. These 
affections can only be diagnosed by their results, except in the case of the 
Optic nerve, where the Opthalmoscope comes to our assistance. 

Causes may be Traumatic or the result of pressure, as in the displaced 
shoulder where the head of the bone presses upon the nerves in that region. 
A Tumor of the brain may cause a descending Neuritis. Very often 
exposure to damp and cold weather is a cause, especially in persons 
of a gouty or rheumatic diathesis. Syphilis is a common cause. The 
above are the most common causes. 

The Lesions are very simple. We find a swelling of the sheath, con- 
gestion, some little oedema, and doubtless some proliferation of fibro-cellular 
tissue. If this last, it is followed by contraction and pressure of tissue on 
the nerve fibrils, and they become more or less strangled and atrophied. 

The Symptoms are — i. Pain. The detection of the painful points is 
very important. They may be over the main trunk, or on some branch 
where it is superficial; e.g., the superficial cutaneous nerve may be very 
tender in brachial pressure. We frequently find cases where, at different 
parts, there are points of nerves in a state of inflammation. 2. We have an 
Affection of Sensation. The part below has a feeling of numbness and 
tingling. If it be a nerve of special sense, that sense would be affected, as 
the eye or the ear. It is curious to note that, after a spell of pain, we may 
have a sudden eruption or herpes on the skin. These eruptions may be 
scattered or grouped, according to the direction of the nerve fibres; e. g., 
in the intercostal spaces we may have Herpes Zoster. This is due to a lack 
of nutrition in the skin. We may have an interference with the 
nutrition of the skin owing to an affection of the veins. AVe may have 
Twitchings of Muscles, and at times tonic spasms. The muscles 
become weaker and more or less palsied. Their electrical reaction 
is impaired, and finally they may undergo atrophy. Thus, we see that all 
the influences which nerves exert are impaired by neuritis, or pressure on 
the nerve. Our mind should be impressed with the idea that it is an affection 
of frequent occurrence. Its existence has frequently been mistaken for 
rheumatism, or it has been referred to the spinal chord. 

The Prognosis, if the affection is recognized sufficiently early, is 
favorable. 

The Treatment is both Local and General. In the early stage it is 
well to leech over the affected nerve, so as to relieve local congestion. This 
may be followed by Iodine frequently repeated, and if the inflammation is 
of long standing, by a Cautery. The pain may be allayed by a Liniment 
of Chloroform and Aconite. The effect is due to the local action of the 
Aconite. 

R Tinct. Aconit. Radicis, 

Aquae Ammonias Fortioris, 

Tinct Opii. aa ^ss, 

Lin. Chloroform f 5ijss, 
or we may use — 

R- Hydrag. Protiodid. §i, 

Yeratriae gr. xxx to Z'\, 

Cosmoline q. s. ad. 51. 



3§ 

This latter never reddens or blisters the skin. It causes a sharp tingling. 
It must not by any accident be carried to the eye after scratching, as it 
induces a severe conjunctivitis. We may make use of a saturated solution 
of Iodoform in Collodion, according to the following Recipe: — 

R Iodoform 3iBi, 

Collodion q. s ad. f %i. 

This, when painted on the spot, acts by contraction and the local action 
of the Iodoform. Sometimes it is necessary to give Opium Suppositories, 
or Morphia hypodermically. Internally we should be governed by the 
cause and constitution. If the patient has a gouty diathesis, Colchicum and 
the Alkalies. If rheumatic, Iodide of Potassium and small doses of mild 
Mercurials. If the pain is distinctly paroxysmal, give full antiperiodic doses 
of Quinine. Keep up the tone of the muscles by Friction, Manipulation 
(this point is exceedingly important) and the use of Electricity. The 
Galvanic current, with the negative pole over the painful spot, often acts as a 
sedative. When a nerve which is near a joint is the seat of inflammation, be 
careful to prevent anchylosis by gentle passive movement. One of the 
commonest forms of anchylosis arises from neuritis of the brachial plexus. 
A fall may drive the head of the humerus up to the chords of the brachial 
plexus. After a time the arm — which has been treated perhaps as a case of 
sprain — begins to lose flesh. The deltoid may be atrophied. The man is 
unable to raise his shoulder. The physician is equally unable to raise it. 
In this case we have a true anchylosis from inaction of the joint, and from 
the extension of the inflammation to the synovial membrane and thence to 
the sheath of the nerve. 

Neuralgia is usually paroxysmal and unsymmetrical. It may be either 
unilateral or may affect different nerves. In true neuralgia there is no lesion. 
There should, properly speaking, be an altered state of function, but it is 
very often associated with a morbid condition of the nerve, i. <?., peri- 
neuritis or neuritis. It is difficult to say when it exists with lesions or when 
it is purely functional. The Pain often corresponds to the various foramina. 
It is very difficult to say whether we have a depressed state of nervous 
function or whether there is a thickening of the periosteum. It is difficult 
to say in some cases whether the nerves are not a tight fit, while in others 
the nerves, even when fully distended, do not fill the foramina. We must 
therefore look out for local causes ; but there are cases where neuralgia has a 
purely systemic origin. 

In the first place among the Causes of Neuralgia we have a neuralgic 
diathesis often inherited. It is very common in gouty, rheumatic and syphi- 
litic subjects. In gouty subjects it may arise in two ways. There may be 
a local affection of the nerves or we may have an accumulation in the system 
of irritating and ill-assimilated stuff which causes an explosion, resulting in a 
gouty toe or a gouty neuralgia. In syphilis and rheumatism we 
frequently have an affection of the nerves. Again, we find that Anaemia 
and Mal-nutrition are also causes of neuralgia. Neuralgia has been defined 
as the cry of a nerve. It may be connected with atmospheric changes, 
which, owing to the morbid sensibility of the nervous system, affect the 
patient one hundred times more than they would normally. A study of the 
external relations of the patient must be made before we pronounce it 
anaemic. In many cases we shall find climatic influences. In a great 
many localities, as soon as a storm centre comes within a certain number 
of miles, it causes neuralgia. This storm range, as it is called, may extend 
to a radius of thirty miles. In whatever way mal-nutrition is brought 
about, whether by sexual excess, too frequent child-birth, etc., etc., neuralgia 



41 

very often succeeds it. Malaria is a frequent cause, also certain Toxic 
agencies, as lead or mercury. It is associated with irritation of distant 
parts. Ovarian and uterine disturbances frequently give rise to neuralgia in 
women. To the causes of neuralgia must be added the overstrain of 
parts ; e. g. t of the Optic nerve, where we see the over-straining of the eye 
accompanied by impaired accommodation. This gives rise to frontal 
neuralgia. 

The Symptoms of Neuralgia are those of the attack and of the interval. 
The condition in the interval varies, of course, infinitely. There are a great 
many who are anaemic and weak and morbidly sensitive. Particularly is 
this the case with women and over-worked men. Then there are the gouty 
and the plethoric, in which it is the result of undigested and accumulated 
matter. Such persons are well fed, but are the victims of frightful spells of 
neuralgia. An attack is frequently preceded by languor, possibly by chilliness 
and depression of spirits. Then pain comes on, which varies as to its seat 
and intensity according to the 4 particular nerve affected. Sometimes it is so 
severe that patients would gladly bear anything to gain relief. The pain 
may be exquisite, lasting for a few hours, or so many days. There are often 
painful points, corresponding to trunks or branches. When the pain reaches 
its height, there may be nausea, vomiting, or merely disgust for food. There 
may be spasms, especially in neuralgia of the fifth pair of nerves, as in Tic 
Doleureux. When the pain stops, there is often a copious discharge of 
light colored urine. When a patient has suffered a long time from 
neuralgia, we may find changes in the skin, hair and muscles. A lock of 
white hair sometimes marks the track of the nerve, or the skin may appear 
glazed, and the muscle be atrophied. The pain differs in its seat according 
to the different nerves, giving rise to the terms Hemi-Cranial Neuralgia, 
where half the head is affected ; Trifacial or Tic Doleureux, i. e., of the 
fifth pair; Inter Costal, etc., Sciatica, etc., etc. The Viscera are often the 
seat of neuralgia, which simulates diseases of these organs. We have Cardiac 
Neuralgia, i. e., angina pectoris; of the stomach, gastralgia. We also 
have renal and hepatic neuralgia. We also have neuralgia of the various 
portions of the intestines, upper, lower, middle, etc. ; also vesico, uterine 
and ovarian. The seats of neuralgia are unlimited. 

In the Diagnosis of Neuralgia, the particular Nerve affected must be 
discovered and traced. We may frequently discover the cause of the neuralgia 
by following up the nerve to its origin, where we may find pressure and local 
irritation. Spinal caries may cause pain in the side. We should eliminate 
such questions as Syphilis and Rheumatism. Find out the patient's constitu- 
tional peculiarities ; whether he be the victim of Lead Poisoning or other Toxic 
agencies. Malaria or Intestinal Colic is to be diagnosed from Lead poisoning 
and Passage of gall stones. Local Pleurisy might simulate an intercostal 
palsy. Having studied the nerve and the cause of the neuralgia it is difficult 
to form a Prognosis. It is not a fatal disease, but it has an obstinate 
tendency to recur. It is hazardous to promise a complete cure. 

Rational Treatment alone brings success, mere routine treatment is of 
no avail. When there is a strong neuralgic diathesis nothing but a skilfully 
prepared regimen so as to change the entire constitution is any good. There 
is no specific drug for neuralgia. Our first and most important duty is an 
appreciation of the constitution of the patient and an appropriate system of 
hygiene and regimen. In most cases this means building up the system by 
reducing work, removing strain, ordering rest, and securing some healthy 
diversion for the mind, Sometimes this necessitates a change of climate till 
the system is built up. We should recommend the use of Iron, Cod Liver 



42 

Oil, Malt, and Hypophosphites and such tonics as Quinine and Arsenic. 
Quinine as a remedy in neuralgia has been much abused; in some cases, as 
in those arising from malaria, it cures. Arsenic should not be used indis- 
criminately. It is also useful in malaria. In cases of neuralgia arising from 
a gouty diathesis our treatment would be exactly the opposite of that laid 
down above. We should require a restrictive and eliminating diet, cold 
baths, and rubbing with flesh brushes, and whatever tends to counteract a 
gouty predisposition. To relieve pain we must have recourse to certain 
anodynes. Apply cloths wrung out with hot solutions. Chloroform, Aconite, 
Iodoform, Collodion, Veratrum, Camphor, and Essential oils all afford relief. 
Menthol pencils are of service. The most effective way, however, is the 
hypodermic injection of Morphia combined with Atropia near the seat of 
pain. Every thing else should be tried first before resorting to this expedient, 
e.g., Opium suppositories with Belladonna. Many opium and morphia eaters 
have been started on their downward course by neuralgia. Very little food 
should be taken during an attack. The digestion is disturbed. Light should 
be excluded from the room, and, if possible, sleep promoted, and very often 
the patient will awake from sleep free from pain. To induce sleep Chloral 
may be used, either in the form of the hydrate or croton chloral hydrate, in 
doses of gr. xv-xxv and gr. iii-v respectively. Where the stomach is irri- 
table we may find it of advantage to give suppositories of Opium, Quinine 
and Asafcetida. We may give, in gelatin capsules : 

Monobromide of Camphor, 

Bromide of Quinine aa gr. xl, 

M. ft. Pulv. ~Div. in Chart., xx, 

Sig : one every one or two hours till the attack yields. 

Opiates should only be resorted to as a last extremity. During the Interval 
the Treatment should be both General and Local, i. General Treat?nent. 
The Cause must be discovered. Anaemia is to be expected and removed 
by careful diet, regimen and Tonics, absolute rest, change of Climate, Iron, 
Arsenic and Cod Liver Oil. In Plethoric cases cut down the diet and give 
more invigorating exercise. In these cases a Blue Pill once a week followed 
by a Saline Cathartic produces good effects. Every case requires separate 
consideration and Treatment. 2. Local Treatment is important where there 
is reason to think that a nerve is the seat of important morbid changes. 
Galvanism with one pole over the painful point and the other over the origin 
of the nerve. Faradization with the dry metallic brush. Repeated Blister- 
ings over the affected part. The use of the cautery along the Sciatic Nerve. 
Nerve Stretching should be tried before Excision. The nerve is dissected 
out and stretched with the handle of a Scalpel. The Function is soon restored. 
A portion of the Trifacial nerve has been successfully dissected out, the 
bones sawed away and the ends of the nerve cut, and they have united. 
Acupuncture is in use in China, and is highly recommended. 

Epilepsy has been called a Functional disease because there is no constant 
organic lesion associated. It is a chronic affection of the nervous system, 
characterized by sudden spells of unconsciousness, occurring at irregular in- 
tervals with or without convulsive movements. 

Causes and Pathology. There is no doubt an element of morbid 
irritability of some reflex center, or a partial loss of the inhibitory action 
of the nervous system. If disposed to it, Impaired Nutrition may cause 
Epilepsy in some persons, while in others the same thing might produce 
simply Biliousness. Increased irritability and impaired inhibitory power 
make patients liable to shock which may be external or internal. In this 
disease the gray matter and cells are injured in some part of the motor track, 



45 

especially in the top of the cord. There may be some gross lesion, as a 
spicula or fracture pressing on a nerve, a thickening, tumor, etc. These are 
called Epileptiform. We limit Epilepsy to cases where there are no lesions. 
Epilepsy is a chronic disease lasting for many years ; perhaps thirty or forty 
years. Sometimes it can be stopped, or it stops itself. It is characterized 
by sudden spells of unconsciousness. There may be twenty attacks a 
day, or they may occur after an interval of years. Sometimes spells are very 
regular ; but this seeming regularity does not endure. If they are very brief, 
and unattended with convulsions, it is called Petit Mai. We may have an 
Aura. It may be painful. At other times it is only a subjective taste, 
sound, or flash of light, which warns the patient. 

Symptoms of the Spell : The patient turns white, instantly loses 
consciousness, falls, and before he reaches the ground there is alternate 
contraction and relaxation of muscles, something like a convulsion. This 
may affect only a few muscles, or it may affect a whole apparatus, as the 
muscles of the chest, tongue, etc. The patient is thrown about on the 
ground, and the convulsion lasts from a few seconds to many minutes. The 
face becomes purple by venous engorgement, the eyes are prominent, 
the veins distended, and the mouth full of bloody foam. After the con- 
vulsion ceases there comes a stage of stupor, with coma, deep sleep, heavy 
breathing, slow pulse, and remaining venous stasis. This lasts for some 
minutes or many hours. The patient then usually returns to consciousness 
and is seemingly well. In coming to, there is often developed a stage of 
excitement. The patient is uncontrollable, violent, homicidal, or in some 
other way insane. Post-epileptic mania is a frequent development. The 
patient may be prone to steal, murder or arson. Many persons have been 
hung for crimes committed under such condition. The general health 
may be preserved, but after a time there is loss of ambition and sustained 
energy. The effect on the mental faculties is worse ; but there are 
exceptions. Napoleon, Caesar and Mirabeau suffered at intervals from this 
condition. Eventually the memory fails, while the mental calibre deterio- 
rates. The character deteriorates, the patient becomes difficult to manage, 
is quarrelsome, and develops vicious traits unknown before. Even where we 
have Petit Mai we may have great nervous changes. An epileptic is disposed 
to many criminal and unnatural acts. The patient generally ends with 
development of feeble nervous tone, and passes into a state of slow 
softening of the brain. Epileptics often injure themselves by falling or 
by drowning. 

Prognosis is very serious, even when there is no organic disease of the 
nervous centres. Some cases stop, others may be stopped. The prognosis 
is grave and should be guarded. The prognosis of the lesser form of epilepsy 
is no better than the more serious. The rarer the attack and the more dis- 
tinct the exciting cause the better the Prognosis, for then the attacks may be 
avoided. If there be evidence of organic disease, i. e., Epileptiform, the 
prognosis would be more grave. 

Diagnosis. It is very important to recognize it at the outset. Early 
treatment is vital. One attack predisposes to another. Professors Parker 
and Dercum found that resting their hand on one object and keeping 
their attention on another brought on epilepsy without unconsciousness. 
Nocturnal attacks often escape attention. The patient may have the tongue 
cut by the teeth, due to unnoticed attacks at night. These spells are often 
overlooked and called "weak spells" and "fainting spells." It is easy, 
however, to distinguish such spells from those of true Sy?icope. The convul- 
sion itself is easily distinguished by the recurrence of it at regular intervals. 



46 

They may be distinguished from Convulsions of Urcemia, in which albumin 
uria would be found. Look for causes in old fractures, tumors, etc. Be 
careful to distinguish them from Hysterical convulsions, particularly from the 
Mongrel Hystero-epilepsy, in which we have hysteria and convulsions; but 
these present themselves after injuries to the spine or pressure on tender 
ovaries. Here the movements are rhythmical, the body afched, the tongue 
is not bitten, and the patient is not profoundly unconscious. There is also 
memory of the attack and recollection of what is said in the hearing of these 
patients. The Treatment is excessively important. We must search for 
the cause and appreciate the constitutional state. Exclude all local irritation, 
adherent prepuce, worms, morbid dentition and injured spine. Exclude 
Meningitis and Tumors. Having excluded these, we must go further, and 
study the constitutional condition. We must realize what the change is that 
brings on the attack. Is it external, or is it brought on by some change in 
the patient's condition? There may be regular symptoms which precede 
each attack, and we may ward off each attack by the administration of Blue pill, 
Saline laxatives, Emetics, etc. Having done this, study the means of aborting 
the " spell." If there is an "aura" let the patient take an inhalation of 
Nitrite of Amyl, and if it is so seated that we can intercept it this should be 
done. If the Aura start from the thumb, let the patient wear a rope around 
the arm, and by suddenly twitching the cord the Aura may be intercepted. 
Keep Nitrite of Amyl in a little bottle loosely corked, and a succession of 
whiffs may break up the spell. Prince Rupert's Capsules are too hard to 
break. A bottle is best. 

Treatment of the Chronic Form. Put the patient on diet. Study 
the digestion, secretions, etc., and adapt the diet to the patient's system. 
Sometimes an exclusive milk diet acts wonderfully. As a rule not much 
meat or rich food should be given. But in boys and girls we often find im- 
paired nutrition, and in these cases we must resort to good feeding and con- 
finement to bed. We must enforce rest. The diet must be in connection 
with exercise and enforced rest. The most important thing is the regulation 
of the intellectual life — study, occupation, amusement, etc. Use the various 
bromides, as Potassium, Sodium, and Ammonium, as these are most import- 
ant in the Interval, and exert a wonderful influence ; but their action is very 
irregular. If a patient puts into his system xxx. to lx. grains every day for 
years, it sometimes is perfectly successful. But sometimes, though the bro- 
mides do stop the attacks, they may bring out troublesome eruptions, crops 
of boils, or even ulcers. Give Arsenic with the Bromides, or they may cause 
bromism. There is often a state of bodily and mental weakness. This may 
be warded off by Strychnia. We sometimes have to change the bromides. 
The patient may be worse off when in a condition of Bromism than in the 
epileptic fit. Sometimes the bromides will not act at all ; they are not 
specifics. When one bromide will not act, try another, or two together. 
Vary the dose according to the age and effect. Combine some tonic where 
the digestion is impressed and the patient is weak and anaemic. The follow- 
ing prescription has been found useful : 
R Potassii Bromid., 

Sodii Bromid. aa ^iij, 

Spt. Ammon. Aromat. f^vi, 

Inf. Gentian Co. f^iv, 

Tinct. Gentian Co. q. s. ad. fSfvi, 

M. ft. S. f3ij, t. d. in water. 
This is a tonic and antacid. We may give Chloral by enema, grains x to xx. 
It must be retained. Valerian, Hyoscyamus, Cannabis Indica and Bella- 
donna do good in some cases, but are inferior to the Bromides. The Salts 



49 

of Silver and Zinc, e. g. t Oxide of Silver and Valerianate of Zinc, are useful 
where there is Gastric Derangement. Nitrate of Silver acts locally, but is 
absorbed, since it discolors the skin. All other known remedies have been 
used, but without effect. Root of White Peony has been recommended. 
Trephining may have to be resorted to, and Circumcision. In very rare 
cases Castration and Amputation of the Clitoris. Local Counter-Irritations 
to the base of the Brain and Spine are good. 

Chorea or St. Vitus Dance is a Functional Disease of the Nervous System 
characterized by involuntary irregular chronic movements, occurring chiefly 
in the Voluntary Muscles, but also in all parts of the body. It appears in 
two forms. The ordinary Sub-Acute and the Grave-Acute. The seat is 
about the Corpus Striatum and its associated motor centres. It is not in the 
chord. The motor centres of the Cortex are often implicated. These parts 
may be in a state of weakness and undue irritability, or there may be a con- 
dition of enlargement and congestion, or the little vessels may be plugged 
with Emboli or Thrombi. Hence we have an interference with nutrition. 

Causes are Predisposing, e.g., Childhood. The vast majority of cases 
occur between the ages of seven and seventeen. Female Sex. Many 
more girls than boys are affected. All Bad Hygiene disposes to it. 
Heredity. The children of weak and neurotic parents are more liable to it. 
Exciting. Severe Shock may bring it on. Rheumatism develops 
it by — i. Weakening the system. 2. By inducing Endocarditis. 3. Little 
particles are detached from the valves of the heart, and these serve as Emboli. 
In many cases we have mitral murmurs. Irritation keeps up Chorea, e.g., 
Wo?-ms, either Seat or Lumbricoid. A splinter under the nail. In adults 
chorea may start during Pregnancy. Imitation will start a whole school. 
We have had Epidemics of this disease among adults in Convents. 

Symptoms at first may be one sided. This form is known as Hemi- 
Chorea (like Hemiplegia) but usually both sides are involved. There may 
be Contortion of the muscles of the hand or face, and jerking of the limbs 
till there is almost constant uncontrollable and extreme grimacing and jerk- 
ing of the whole muscular apparatus. The Gait is awkward and shuffling. 
The child drops solid articles, spills liquids, sticks itself with its fork, and 
has to be fed. We call such movements Choreic. // is not a Tre7nor but a 
violent jactation. The movements occur when the child is trying to use 
a limb. They are increased by excitement. On the other hand, they nearly 
always cease during sleep. Nearly all the muscles, but more particularly the 
voluntary, are affected ; yet the Bladder, Rectum, Muscles of Respiration, 
and even the Heart may be affected. Sometimes speech, which is nearly 
always affected, becomes very much so. The child can hardly enunciate his 
words at all. The Mind, for the time, seems impaired, and there may be 
downright mental debility. Muscular Debility may degenerate into palsy 
of one-half of the body. The Sensibility of the skin is impaired. This 
is particularly seen where the child dashes itself on the ground and doesn't 
seem to mind it. The Reflexes are blunted. 

Duration. It develops gradually, runs an uncertain course, three or four 
weeks to as many months, and gradually diminishes. 

The Acute or Grave Form comes on suddenly in adults. The move- 
ments are frightful. Eating is impossible. The patient cannot lie in bed. 
The Room has to be padded sometimes. Very often Delirium is associated, 
and there is some Elevation of Temperature. Rapid Emaciation 
takes place, so that this form of Chorea may terminate in seven to twelve 
days. In this disease the Cortical Centres are seriously affected. 



5o 

Diagnosis is very easy. The movements cannot be mistaken. In Dis- 
seminated Sclerosis we have something similar. 

Prognosis is, in the Ordinary form, very favorable. Chorea is not dan- 
gerous to life, but is doubtful as regards time. In children it is very apt to 
return in the following spring, owing, probably, to too hard work in school, 
poor feeding, etc. The Prognosis of Acute Chorea is very unfavorable. It 
is apt to become chronic. 

Treatment of Ordinary Chorea. We must attend to the general habits 
of the child. It must be removed from school and sent to the country. 
Adherent prepuce, if existing, must be removed, also Gastric Irritation and 
Seat Worms must be treated. Iron is a remedy of almost universal applica- 
tion. With this we may associate Arsenic. To do good this must be pushed 
to its utmost. Fowler's Solution given immediately after eating and well 
diluted, gtt i to ii at first and then increased till symptoms of Arsenic poison- 
ing appear. Sometimes it may be given hypodermically. Cimicifuga in 
the form of the fluid Extract or the Decoction is worth a trial. Arsenic may 
be given with it. Iodide and Bromide of Potassium are particularly valuable 
in cases of Rheumatism. Strychnia is deserving of attention, and where 
there is impaired nerve-action, pushed in ascending doses, it is very useful. 
Begin with very small doses, and look out for its physiological action, such 
as Tonic Contraction of Muscles. Ether Spray along the Spine, and Anodyne 
liniments. Careful Muscular Exercise and Calisthenics. Salt Water bath- 
ing. Friction and General Hygiene. 

Treatment of Grave Chorea : All we can attempt here is to secure sleep, 
and administer nourishment, i. Give Chloral Bromides, Opium, Anodynes. 
2. The introduction of Food in the best possible manner must be secured. 

II. DISEASES OF THE KIDNEY. 

The Urine should be examined in all cases, whether Acute or Chronic. 
We study : — i. The Quantity; 2. Color; 3. Specific Gravity ; 4. Reaction; 
and 5. The Presence of Abnormalities. 

I. Quantity. The normal amount per diem varies from one quart to 
three pints. It may be — 1. Diminished (a.) by Diarrhoea, as in Cholera, Yel- 
low Fever, etc. ; (b) by Sweating; (c) in Nephritis; (d) in Hysteria. 2. 
Concentrated, as in Fever. 3. Suppressed, e. g., in Hysteria. 4. Increased, 
1. Where the Skin is inactive. 2. Where a large amount of Liquid has 
been taken into the System — especially is this the case where there is no 
Sweating, or the patient constipated. 3. After a Hysterical Crisis. 4. During 
Convalescence from Acute fevers. 5. When Liquid Effusions, as Dropsy, or 
an Ovarian Cyst, are suddenly removed. 6. In the Disease called Poly- 
uria, where for a long time large amounts of a light color and low Sp. Gr. 
are discharged, with no increase relatively in its Solid Constituents. 

II. The Color is closely connected with its concentration. It is Dark — 
1. When of Small Amount. 2. In Congestion of the Liver. 3. When there 
has been much disintegration of the red blood corpuscles, as in Malaria. It 
is bile-stained in Jaundice. In Haemoglobinuria it is claret-colored. This 
occurs in certain conditions, e. g., in rupture and consequent absorption of 
the clot in extra-uterine Fcetation. 

III. Specific Gravity is of importance only when taken in connection 
with the amount. Thus the Sp. Gr. in fever may be 1040. In anaemic 
persons it is low, from a lack of solids taken. In Diabetes it may be as high 
as 1070. 



5i 

IV. In this connection we consider the Symptoms of three important con- 
ditions, viz. : Anuria, or Suppression of Urine ; Diuresis, or excessive 
Secretion of Urine; and Diabetes. 

I. The Symptoms of Anuria differ according to the cause, i. Where 
it proceeds from obstruction, what urine does escape is normal. The 
other Symptoms depend on the obstructing cause. If a Tumor, it would be 
found on Palpation. For several days the patient gets on pretty well ; then 
comes distress, restlessness, pain, and then we have the evidences of 
absorption and the slow development of Uraemia. There is loss of appe- 
tite and nausea, dullness deepening into Coma, and the patient dies. The 
duration may be from one or two to ten or twelve days. 2. When there is 
Complete Suppression from other causes the few drops we do obtain, 
if it comes from acute Congestion, are highly concentrated, containing 
Epithelium and Tube Casts. On the introduction of the Catheter we may 
only obtain a few teaspoon fuls. There is fever, distress, loss of appetite ; not 
rarely severe iNervous Symptoms and Convulsions. Vomiting is not rare, and 
is partly dependent on the retention of irritating matters in the blood. The 
patient may pass into a Typhoid state. 3. Lastly, where there is Hysterical 
Suppression the Pulse is tranquil, the tongue clean, and the expression 
natural. Sometimes we have Hysterical Vomiting, which is sometimes so 
profuse, and tainted with a urinous odor, that we think there must have been 
a discharge of some excrementitious material. There may be an absence of 
Nervous Symptoms. Then the flow may be re-established. What little there 
is may be normal. When there is no Cause of obstruction, and where the 
symptoms indicate a hysterical element, we should be on our guard against 
imposition. 

Diagnosis. The first point is to establish the reality of Anuria, next the 
nature, and thirdly the attendant symptoms. 

Prognosis. If it arises from a Tumor, whether outside or inside, the 
case is hopeless. Treatment. In case of impacted Calculus, the question 
comes up of surgical operation, when it has lasted long enough to threaten 
death. It is vain to attempt to flush out the stone. The diet must be of such 
a nature, and drink restricted so as to lessen the secretion ; for if the stone is 
not too large, and the tube is normal and elastic, even though the size of the 
one and the spasm of the other prevented its passage, favorable results may be 
obtained. Large doses of Hydragogue Diuretics must not be given. They 
rather do harm. Where the Anuria is due to suppression, from active con- 
gestion of the kidney, and the urine is bloody, albuminous, and contains 
blood casts, we must afford relief through other channels. Sweating should 
be promoted through Vapor Baths and by Jaborandi, and if this is not retained, 
by hypodermic injections of Pilocarpin, repeated according to its effect. At 
the same time we should promote a light laxative action of the bowels. 
The diet should consist of little more than skimmed milk. All stimulating 
diuretics should be studiously avoided. The restlessness and nervous symp- 
toms should be controlled by Chloral and the Bromides. Opium should be 
avoided. Codeia and Hyoscyamia are safer. Cocaine in one of its salts, 
given hypodermically or internally, is both sedative and diuretic. It is very 
reliable, and by a continuance of this treatment favorable results are 
obtained, even when the prolongation of the condition makes it seem 
incredible. W T hen it has come from Nervous Shock, and is attended with a 
Hysteroid element, large doses of Asafcetida and Valerian, combined with a 
derivative treatment, are indicated. 

II. Diuresis. When the Urine is in excess of the normal, we say we 
have the Symptom of Diuresis. The amount may go up to 80, 90, 100, 



52 

III. Diabetes. This is a derangement of assimilation, marked by copious 
saccharine urine, deficient secretion of the skin and mucous membranes ; great 
thirst and appetite, progressive loss of flesh and strength ; temporary or perma- 
nent in its character, and often fatal in its result. The word means " a going 
or flowing through." It is used now to signify the whole condition. We 
omit the word Mellitus. We refer only to one condition. Polyuria and 
Diuresis are used instead. 

Causes are such as disorder the complex relation between the Nervous 
System and the Kidney, Stomach and Liver. We find very Varied Causes. 
In the first place it follows prolonged and excessive mental strain, 
particularly if accompanied by Dietetic Excess, if the Nervous System is 
deranged by injury, especially in a certain region. Hence, Functional 
derangements dispose to, and Organic lesions cause it directly. It may ensue 
on derangements of the Liver, Pancreas, and possibly the Stomach, where 
Sugar undergoes certain alterations, ultimately becoming alcohol and car- 
bonic acid. Starch is first converted into Sugar. We each can dispose of 
a certain amount of sugar and starch as long as the Liver, Pancreas, etc., are 
normal. But on taking too much sugar we would recognize it in the secre- 
tions. This is Physiological and Transient. It is very different from the 
Pathological. The Liver produces an animal sugar — "glycogen," which has 
a saccharine element. It can be produced from meat. It is not improbable 
that in some cases there is an excess of this function. This may be another 
mode of production. The intimate nature of this process is very complex. 
In recognizing the presence of Sugar, we by no means get at the true cause. 
Sex. It is more common in males. Heredity. It is sometimes substi- 
tuted by Gout, Rheumatism, Bright's, or some serious Nervous Disease, as 
Epilepsy. It has an affinity with other diseases which result from disturb- 
ances of assimilation. Race. It is exceptionally frequent in Jews. No 
explanation, except the close inter-marriage of this race, is as yet satisfactory. 

Symptoms are very marked. The cases begin acutely or gradually. 
An Acute may run its course in a very few weeks to a fatal result, but usually 
lasts for years. The age at which it begins makes a difference. The younger 
the child the worse the case. Excessive Urination, or Polyuria. Even- 
time there is a considerable amount discharged; but there may be Diabetes 
with fifty ounces of urine. As much as fifteen or sixteen pints in twenty-four 
hours may be passed. This urine is of a pale color ; has a sweetish, mawkish 
smell, like new-mown hay. The urine dries and leaves a whitish stain. Its 
specific gravity is higher than normal. The increase of density is due to the 
sugar. This urine contains glucose. Loss of Sexual Function or Impotence, 
is one of the most prominent symptoms of which patients complain, and also 
of Pruritus of the Genitals. The fermentation of the urine irritates the 
Genitals and thighs. Perversion of Appetite, the patient eating largely, 
but not being satisfied. There may be morbid craving. Thirst is almost con- 
stant. The Tongue is red and dry. The Mouth is dry and pasty. Despik 
this ingestion of food and drink, the strength and flesh progressively 
fail. The patient feels dragged out, loses his interest and energy in his 
pursuits. Perspiration is scanty, and almost absent. The slightest irrita- 
tion produces Boils, and even Carbuncles. Slight injuries produce Slough- 
ing and Gangrene ; hence operations are fatal. Death occurs either from the 
development of phthisis — this is peculiarly latent, rapid, and uninfluenced by 
treatment, the Nervous Centres being blunted — or from Malnutrition, 
Bright" s Disease, or there may be a Paralysis of some Nervous Centre, 
associated with hypei'-pyrexia. It may be entirely cured, but complete cures 



are rare. It may be kept in check. Relief alone can be hoped for. We 
may have Diabetes of an intermittent character. 

Diagnosis is very easy. Our suspicions being aroused, simple examina- 
tion of the urine reveals it. 

Prognosis is gathered from what has been said. It is hopeless in cases 
of organic disease. Yet, it is bad if the disease is hereditary ; bad when it 
appears in young subjects; bad when after cutting off Sugar from the diet, 
it yet appears in the urine. It is very bad when symptoms of Bright's dis- 
ease are combined. It is hopeless when phthisis has appeared. When it is 
mild, it may be cured. 

Treatment. It is principally dietetic. Certain articles can no longer 
be assimilated properly. We must cut off Starch and Sugar from the diet 
then by using proper hygiene, the complex combination of the system may 
be repaired. Avoid all articles which contain Sugar, e. g., Milk, Malt Liq- 
uors (which also have starch). It is more serious in reference to Liquids. 
Glycerin can be converted into a Saccharine matter in the body. " Man- 
nite " may be worth a trial, but it is better that the patient should learn to 
do without it. The Vegetables, Cereals, etc., must be set aside. Let him 
use gluten bread, crackers, or mush, or bread made from almond flour. 
Lemon juice may be allowed. The bill of fare must be carefully prepared and 
the preparation varied. A little acidulous wine or freely diluted whiskey 
and gin may be allowed. But their avoidance is better than their use. 
There should soon be a material improvement. If you get no change, let 
the patient go back to mixed diet. Some are better when there is a little 
sugar in their urine. The skin must be protected and Temperature must be 
maintained by avoiding excessive fatigue. The least irritation must be 
avoided. Mental fatigue and worry may induce a rapidly fatal result. 

Drugs. The alkaline mineral waters, weak solutions of the carbonates, 
and certain waters, as our own Bedford or Carlsbad, Clysmic, and Vichey, are 
valuable, and combined with hygiene are most useful sometimes. Opium and 
Codeia may be used with advantage, as tending to restrict the excessive 
craving for drink and to check the urine. When well borne, gr. xv per 
diem have been taken. Nutrients, as Iron and Cod Liver Oil, are useful, 
but must be given with reference to the Stomach. On special modes of 
Treatment, as Skimmed Milk, some recover. Some do well on " Koumyss," 
in which the sugar has been fermented and the casein disintegrated. Ergot 
will check the flow of urine, but will not check the disturbed function of 
assimilation. The Bromides may allay irritation of the Nerve Centres. 
Bromide of Arsenic, combining the sedative quality of Bromide with the 
alterative action of the Arsenic, has been recommended. First cautiously 
restrict the diet. Gradually bring the patient down to a Diabetic diet. 
Then get at the true cause and adapt your drugs accordingly. If Hepatic, 
the Liver must be treated. If it is Nervous, nutrients and the Bromides of 
Arsenic are indicated. If neurotic, give Bromides and Cod Liver Oil. In 
connection with disorders of digestion, the following Prescription presents 
a convenient combination. 

R Strychnia?, gr. ss, 

Acidi Nitro Muriatici Diluti, foii-iii, 

Pepsin, gr. xxxii, 

Glycerin or Tinct. Cardamon. Co., f^ss, 

Aquam ad, f.^iv. 

Mft. Sign : f^i ter die post cibum. 



53 

IV. Reaction. This should be taken immediately. I. Acidity is marked 
in Indigestion, Rheumatism, etc. It is rendered neutral by taking Alkalies. 
2. Alkalinity occurs — i. In Cystitis from the development of Ammonia from 
the Mucus ; 2. From the reception of too much Alkali, e. g., in Rheumatism. 

V. Detection of Abnormalities. 

1. Albumen. A slight amount may be consistent with health. We must 
not assume from a trace of Albumen that Nephritis exists. On the ingestion 
of food it is physiological, and there is a functional Albuminuria. 

2. Phosphatic Diathesis. We have primarily a deranged action of the 
stomach. The urine is pale, and readily undergoes decomposition. It is 
generally neutral ; but, when acid phosphate is present, its reaction may be 
acid. On boiling we get turbidity, which clears up on the addition of Nitric 
Acid. Microscopic examination reveals the presence of phosphatic crystals. 
Atonic Dyspepsia usually co-exists, also anaemia and nervous debility. It is 
not due to nervous exhaustion primarily, but rather to nervous indigestion. 

The Symptoms are usually those of the condition causing this state, 
rather than symptoms referred to the kidney. 

Diagnosis is easy by Chemical and Microscopical tests. 

The Prognosis is favorable. There is less danger of Calculi forming 
than in the Uric acid diathesis. 

The Treatment has reference to the general health and the underlying 
conditions. It is difficult to lay down rules for diet. Most cases do well on 
a nourishing diet without much saccharine or farinaceous foods. Vegetables 
and fruit and a moderate amount of exercise may be allowed. As tonics we 
give mineral acids, strychnia, and vegetable bitters. 

3. Uric Acid Diathesis. The urine is high colored and of a high 
specific gravity and of a strongly acid reaction. After the addition of Nitric 
Acid we have, on boiling, a reddish, sandy deposit, either of pure uric acid 
crystals or of one of its salts. This is called "Brick-Dust" or Lateritious 
deposit. This condition is found in connection with the Gouty Diathesis. 
It is seen in high livers and hard drinkers, and in those who take insufficient 
out-door exercise. 

Symptoms of Lithaemia. The tongue is red and coated. The stomach 
irritable with acid dyspepsia. There is a disposition to bilious derange- 
ment with dull headaches. The bowels, particularly the lower, are con- 
gested, with a tendency to hemorrhoids. There are wandering rheu- 
matic pains. 

The Diagnosis is easily made from an examination of the urine, and 
from the character of the patient. 

The Prognosis is rather serious from the tendency to Renal and Vesical 
Calculi — most Calculi containing a uric acid nucleus — and from the difficulty 
experienced in inducing the patient to give up his injurious habits. 

The Treatment is dietetic and regiminal. Restrict the diet. Highly 
seasoned and sweet dishes, alcohol, etc., must be prohibited. Recommend 
outdoor exercise strongly. This condition is often seen in women at the 
menopause when they have no call for exertion. Depurative remedies as 
alkaline and mineral waters, e.g., Karlsbad, Vichy, or diluent waters, as 
Poland, are useful. When secondary troubles arise we may require Potassium 
Iodide and alterative diuretics. 

4. Oxaluria, or Oxalic Acid Diathesis is a modification of the last. 
It is often associated with the presence of urates or of phosphates. The 
urine is pale, somewhat acid, and contains mucus. Rarely do we have a 
copious deposit. This condition is associated with the same tendencies as 
the last. The digestion, however, is weaker, and there is a more pronounced 



54 

tendency to nervous disorders, e.g., Hypochondriasis. Oxaluria is 
merely a symptom of nervous dyspepsia. It may be caused by the ingestion 
of Rhubarb. 

The Diagnosis is not very easy. The deposit is small and often over- 
looked. 

Prognosis is perplexing. Cases are hard to relieve. There is not, 
however, so much tendency to the formation of calculi as in the uric acid 
diathesis. 

The Treatment in some cases is that of Lithaemia combined with a tonic 
stomach treatment. 

II. Renal Calculi. These may occur in the substance of the Kidney, in 
the pelvis, or in other places ; thus giving rise to various anatomical results, 
£. £., Suppurative Inflammation or Suppurative Nephritis. In the Pelvis or 
Calix, Pyelitis is common. Obstruction of the Calix may cause a Retention 
Cyst. Where the ureter is obstructed we may have a cystic Degeneration 
leading to Hydronephrosis. Symptoms vary with the locality of the calculi. 
i. Where they are Imbedded in the Substance the Symptoms are 
obscure. There is more or less pain in the back which may simulate 
Neuralgia, Lumbago, etc. Reflex symptoms, e. g. , Neuralgic pains or 
dyspepsia are set up. There are no distinct changes in the urine. The 
calculus may remain encapsuled or may get into the pelvis. 

2. Calculi in the Pelvis and passing downwards give rise to Renal 
Colic with intense pains which come on suddenly. There is pain at the 
end of the penis, retraction of the testicles and a frequent desire to 
micturate. The patient is pale, and vomits. The extremities are cold. 
The first urine passed, after an attack, is bloody. The blood may disap- 
pear in two or three days. The pain may end as suddenly as it began. As 
soon as the calculus drops into the bladder the pain stops. 

The Duration of the attack lasts from a few minutes to as many days, de- 
pending on the size and shape of the stone. This varies from a pin's head to 
a date seed. The stone may come away with the urine immediately after an 
attack. If not discharged it may cause Cystitis, and deposits form about 
it as a nucleus. It occurs most frequently in males, usually adults. There 
may be only one attack, or several. 

Diagnosis, i. From Passage of Gall-Stones — i. The pains do not 
radiate to the shoulder. 2. There is less vomiting. 3. There is straining at 
micturition. 4. Jaundice is absent. 5. The stone is not found in the stool, 
but may appear in the urine. 6. Haematuria is common. 

2. In Intestinal Pain — 1. The pain is in front, about the umbilicus. 
2. The attack is not so sudden. 3. There " may " be straining at mictu- 
rition ; but 4. We have no haematuria. 5. There is a history of cold, eating 
indigestible food, etc. 

3. In Lead Colic we have a history of poisoning. 

4. In Nephralgia, or Neuralgia of Kidney, there is — 1. No Haema- 
turia. 2. No stone in the urine. Otherwise they are not distinguishable. 

Prognosis is favorable for life. Patients rarely die, but usually are liable 
to more than one attack. 

Terminations. 1. There may be Occlusion of the Ureter by 
large stone. There is fixed pain, fever and evidences of resorption, and then 
uraemia. Death often results. 2. The symptoms may subside. The 
sound Kidney does the work of the other, discharging normal urine. The 
stone may even crumble and be discharged. 

Treatment. 1. During the Attack, Hypodermic injections o 
Morphia, Opium by the Rectum, or Chlorodyne by the mouth. When 



57 

the attack is very severe, we may have to administer an anaesthetic. The 
patient must be kept warm and quiet, and hot applications made to the 
back. Give warm diluent drinks, and, for a couple of days after the attack,, 
keep the patient at rest. 2. To avoid further Formation, treat the 
corresponding urinary Diathesis, which is usually the Lithic. 

Results of Renal Calculi. 

Pyelitis, or Inflammation of the mucous membrane of the pelvis of the 
Kidney. 

Causes. 1. The presence of Calculi. 2. It may succeed a dis- 
charged Calculus. 3. The sudden checking of perspiration by the 
action of cold. 

Symptoms are Pain and Tenderness in the region of the Kidney, 
increased by rough movement. Muco-pus is discharged with the urine, 
but there is less mucus than in Cystitis. The supernatant fluid contains 
albumen corresponding to the amount of pus. There is frequent mic- 
turition, and Epithelial cells from the upper portion of the ureters 
appear, but tube casts are absent. Patients grow very anaemic, and 
CEdema of the feet may supervene, thus simulating Nephritis. 

Prognosis is serious. The disease is liable to be chronic. It is hard to 
cure, and relapses are frequent, particularly where the calculus is retained ; 
this keeps up the inflammation. The presence of blood in the urine, with 
spells of colic, should make us suspect this condition. 

Treatment is unsatisfactory and indirect. We must treat the existing- 
diathesis. Rest is important, and must often be absolute. Protracted mild 
counter irritation over the Renal region, together with the use of mineral 
waters and the administration of alterative Diuretics, e. g., Fluid extract of 
Buchu and Uva Ursi, and Triticum Repens, are indicated. Belladonna is 
often associated with these diuretics. 

R Liq. Potas. m. v-x, or 

Sod. Bicarb, gr. v-x, 
Fl. Ext. Buchu m. viij. xx, 
Tinct. Belladon. gtt. v-x, 
Syr. Zingib. or Sarsap. Co. q. s. ad. f 3 i j . 

In most cases iron must be used for the anaemia. Too many remedies 
must not be given, for fear of disturbing digestion. Much may be done by 
the prolonged use of Skimmed Milk, Koumyss, or Whey. When the inflam- 
mation persists, and the membrane is becoming degenerated, the question of 
excision of the Kidney or of the Stone must be considered. 

III. Congestion of the Kidneys is — 1. Acute. 2. Chronic. 

1. The Acute is only slightly separated from inflammation. 

Causes. 1. The sudden checking of skin circulation, thus throw- 
ing upon the Kidneys, which are the counterpart of the skin, an abnormal 
amount of work. 2. The irritant action of certain substances, e. g., Alco- 
hol, Cantharides, Turpentine, etc. 3. Septic poisons; and 4. Specific 
Diseases. 

Symptoms are obscure, unless the action has gone on to tissue change. 
There is alteration of the Epithelium, with cloudy swelling. The 
urine is frequently scanty, high-colored, with some blood and albumen. 
There are no tube casts, except, perhaps, a few blood casts. The patient 
suffers dull pain, or there may be only a sense of discomfort. Anuria may 
come on, giving rise to uraemic symptoms. 

Treatment. Light liquid diet and diluent drinks should be given. 
Infusion of Digitalis, together with Acetate of Potash, may be used as a 
hydragogue Diuretic. Counter-irritation or depletion may be indicated. A 



58 

blister of Cantharides should never be used where there is any irritation of 
the genito-urinary tract. 

2. Chronic Congestion of the Kidney. 

Causes. Obstructive Disease of the Heart. Where there is 
long-standing chronic engorgement, the Kidney becomes Cyanotic, i. e., it 
presents a bluish induration. It may be present, but in a more imperfect 
form, in Chronic Alcoholism. 

Symptoms are those of the cause. The Urine is copious. Its specific 
gravity varies with the amount. Albumen is quite common. There should 
be no epithelial or granular tube casts. We may find mucoid cylin- 
ders, and rarely Hyaline casts. 

Prognosis. Cyanotic induration usually remains as such, and does not 
run into Bright' s Disease, although such patients are liable to intercurrent 
attacks of Bright' s Disease. It may run into the interstitial form, and Organic 
disease develop from this. 

Treatment of the skin and stomach is very important. Dilute Salines, 
such as mild mineral waters, which can easily be made from solutions of 
Lithium or Potassium salts, should be freely used. The occupation, dwell- 
ing, habits, etc., must be improved. Digitalis and Ergot are indicated to 
influence the blood-vessels and relieve the congestion. Counter-irritation 
should be applied over the kidney, and a flannel belt worn around the renal 
zone. 

IV. Bright' s Disease. Under this we consider Acute and Chronic 
Nephritis in their various forms. 

i. Acute Bright' s may — i. Appear as an acute and primary attack ; or, 
2. As an intercurrent condition. 

Causes are those of inflammation, Sudden checking of the secretion of 
the skin, Specific poisons accompanied usually at the same time by a chill, 
e. g., as in Scarlet fever. When the apparent cause seems to be insufficient, 
there has probably been some chronic condition. 

Morbid Anatomy — i. Macroscopically. The organ is enlarged and heavier 
than normal. The Capsule is injected and easily removed. The veins are 
sharply visible. On section it is very bloody. The Cortex is coarse and the 
Pyramids are deeply red. 2. Microscopically . The Epithelial Cells are affected 
by Catarrhal Inflammation and Cloudy Swelling. There is a rapid over- 
growth and proliferation with an intermixture of some colorless blood cor- 
puscles as well as red corpuscles and tube casts, which may be either Epithe- 
lial and Blood casts or pure Granular casts. The vessels of the Kidney are 
engorged. There is no marked change in the interstitial stroma unless there 
has been some previous alteration. 

Symptoms — 1. General. There is often a Rigor or chill, with mod- 
erate fever and headache. The surface is pale. The pulse is tense 
and full, but only moderately frequent. The breathing is rapid. There 
is often bronchial Irritation or Pulmonary Congestion. Vomiting is 
common, and sometimes we find gastro-intestinal catarrh with loose 
stools. There are dull pains in the loins and soreness on pressure. 
2. Urinary. The urine is diminished in quantity and high colored. 
It may be reddish from the presence of blood, and contains much albu- 
men, with a flocculent sediment of red and colorless blood corpuscles. 
The amount of urine may be nil, or, where micturition is frequent, it may 
be as high as 16 ounces per diem. In intercurrent cases the symptoms are 
less violent. The patient has a blanched, pasty look about the face. 
There is dull headache, and sleep is restless. There is often dullness 
of the intellect, and muscular twitchings may occur during sleep. In 



6i 

children we may find either convulsions or deep stupor. (Edema of 

the face, feet, or ankles may occur early in the disease. Some of these 
symptoms are due to the co-existence of catarrh of other mucous membranes. 
In some cases where they are absent at first, they may develop later from 
blood-poisoning. This may occur very abruptly, giving rise to nervous 
disorders in a few hours after the development of the case. 
Chronic Bright's Disease. 

i. Chronic Catarrhal Nephritis. 

2. Chronic Interstitial Nephritis. 

3. Amyloid Degeneration. 

4. Fatty Degeneration. 

I. Chronic Catarrhal Nephritis is also called Desquamative Nephri- 
tis, Parenchymatous Nephritis, Tubular Nephritis, Large White Kidney of 
Bright. 

Morbid Anatomy. 1. Macroscopically. The Kidney is swollen and 
heavy, friable and less consistent than normal. The Capsule is not affected, 
and strips off easily. Its surface is pale and mottled. On section, the 
cortex is found to be enlarged to two or three times its natural size, is 
coarsely granular, and has a pale, blotchy look. The Pyramids are streaked, 
of a dark red color. 2. Microscopically. The tubules are irregularly filled 
with Detritus. The Epithelium is swollen and desquamating, and Hyaline 
casts are found in the urine. Both Kidneys are usually involved, one being 
generally more so than the other. This form may occur with other forms of 
Bright's disease, and be accompanied with Amyloid and Fatty change. 

II. Chronic Interstitial Nephritis. This is a chronic granular 
degeneration. It may begin as — 1. A primary interstitial process. 2. 
As an atrophic degeneration of cells. 3. More or less Catarrhal Nephri- 
tis may co-exist with it ; or, 4. It may be accompanied with Amyloid 
changes. Hence its appearance is modified. 

Morbid Anatomy. 1. Macroscopically. The Kidney is reduced in 
size and weight, but its consistency is increased. The capsule is thick and 
opaque, and closely adherent. Its surface is rough and granulated, giving 
it a "hob-nail" appearance. The organ is tough and hard to tear. Section 
shows the cortex to be reduced. The Pyramids are pale. 2. Microsco- 
pically. The Epithelial lining of the tubes has undergone atrophy from an 
interference with the circulation. The Epithelium is neither swollen nor 
desquamated. The Interstitial connective tissue is greatly increased. Cysts 
are formed from dilatation of the tubules or Malpighian bodies, owing to the 
contraction of the connective tissue. Both organs are usually uniformly 
involved. 

III. Amyloid Degeneration of the Kidney is not so common. 

Morbid Anatomy. 1. Macroscopically. The Kidney is larger than nor- 
mal, pale, smooth and friable. The capsule is not affected and strips off easily. 
On section the parts are seen to retain their normal proportion, but present a 
waxy translucency. Cysts may be present. 2. Microscopically. The walls 
of the straight intertubular arteries and of the capillaries of the Malpighian 
Tufts are infiltrated with an amyloid material. The tubes contain Hyaline 
Cylinders, which react with Iodine, giving a blue color. This condition 
may be found in connection with Catarrhal Nephritis, or with interstitial 
change. 

IV. Fatty Degeneration of the Kidney. This may occur as a dis- 
tinct condition, but this is very rare. The organ is large, soft, flabby and 
friable, and of a pale yellowish color. On section it is greasy and fatty. 
Casts are found in the tubules. 



62 

General Causes of Bright's Disease, i. Previous acute attacks. 
2. Climatic influences, e. g., great changes in temperature, damp climates 
and districts, faultily drained dwellings, etc. 3. Mal-hygiene of the per- 
son, wet feet, poor clothing, etc. 4. Excesses in eating and drinking. 

5. Various toxic agencies, e. g., Arsenic, Lead, Phosphorous and Malarial 
poisoning. 

The type which the case will assume depends upon the vulnerability of the 
different tissues of the patient, and also is determined by the nature of the 
cause itself. Lead Poisoning and Gout giving rise to the interstitial, and 
Phosphorous and Arsenic to the catarrhal forms. Amyloid and Fatty De- 
generations are brought about by their usual causes. 

Symptoms Common to all Forms of Bright's Disease. 

The earliest and most common are a progressive — 1. Failure of strength ; 
and 2. Loss of color. The anaemia is intense, the patient often assuming a 
waxy hue. 3. The digestion is gradually impaired, and there may be con- 
stant morning vomiting before eating. 4. The condition of the bowels is 
very variable; usually they are sluggish. 5. The heart is often hyper- 
trophied. This is most common in the Interstitial form, and may be asso- 
ciated with Atheroma giving a murmur. May be easily disturbed by a little 
exertion. Palpitation and irregularity of action are common in this form. 

6. The dyspnoea may almost simulate asthma. 7. There is often conges- 
tion of the lungs. 8. Nervous Symptoms may be very marked. 
Vision may be impaired, and blindness even result. Tinnitus Aurium is fre- 
quent, or there may even be Deafness. Giddiness, Confusion of the mind,. 
Forgetfulness and Drowsiness are common, and changes of temper have 
often been noted. 9. CEdema begins usually about the face. When the 
patient is long on his feet it may be very prominent about the ankles. 

10. There is a great tendency to internal inflammation and dropsy, e.g., 
Pleurisy and Pericarditis, especially in Catarrhal Nephritis, etc. The 
closing stages are ushered in by blood poisoning and uraemia. 

Uraemia. This term arose from the supposition that urea is retained in 
the blood and gives rise to the condition. However, not only urea but other 
materials are accumulated in the blood, and further, new derivatives are pro- 
duced, which, in turn, together with the wide-spread changes elsewhere, 
produce the symptoms. It may assume different forms. It may be sudden 
or gradual, and may come on only towards the close of the disease, or at 
any time, as an intercurrent attack. 

Symptoms are : 1. Excessive shortness of breath which is known as 
uraemic dyspnoea. This may come on with increasing drowsiness, mild 
delirium, ending in coma and death. 2. Convulsive attacks. 3. In 
some cases it may manifest itself by uncontrollable colliquitive diarrhoea. 
4. In others the patient dies of pneumonia, dysentery, or apoplexy with 
partial or complete hemiplegia. Apoplexy is most common in Interstitial 
because the Blood Vessels throughout the body are affected. 

11. There is generally more or less discomfort in the back which may 
amount to deep-seated pain. In some cases, however, the pain may be 
entirely absent. 12. Increased frequency of micturition. The patient 
may have to urinate during the night. 13. The Urine may appear natural, 
but is often paler and clearer than normal, especially in chronic cases. It is 
often cloudy from intercurrent attacks of congestion. The Amount in the 
chronic forms is large ; in the interstitial it is excessive. This is known as 



65 

polyuria. In the Catarrhal form it is about normal. In Amyloid Degener- 
ation it is free. In an intercurrent acute attack, scanty. Towards the close, 
particularly in the catarrhal form, the flow is scanty and often suppressed. 
A steady decrease is a bad sign. The Specific Gravity is influenced by 
the amount, but it is generally lower than normal. Especially is this the 
case in interstitial. It is less so in amyloid degeneration and least so in the 
chronic catarrhal form. Albumen is present in all cases of chronic Bright's 
Disease, and is increased after exercise and meals. It is abundant in the 
catarrhal, and scantiest in the chronic interstitial form. In this last it may 
be present only as a trace. It is moderate in Amyloid. Only in extremely 
rare cases is no albumen found. As the urine becomes scantier, albumen 
increases. Urea is nearly always diminished. When uraemia exists, it is 
markedly lessened in the urine, but its odor is exhaled from the sweat, breath, 
etc. Sediment is most marked in the catarrhal form, and consists of Epi- 
thelial cells, Leucocytes, Red Blood Corpuscles, and Tube casts. These 
latter are granular, epithelial, fatty, or hyaline. There may be two or three 
in each drop. There is very little in the Interstitial form. The urine is 
cloudy and there may be a few hyaline casts. In amyloid degeneration, tube 
casts are more numerous. They are larger than in interstitial and may give 
the iodine reaction. 

The Duration of Bright's Disease is from one year to twenty. 

Diagnosis of the Various Forms. 

I. Chronic Catarrhal comes on generally after an acute attack. Dropsy 
is early. The urine is less abundant and of a higher specific gravity, contain- 
ing albumen and tube casts. Inflammations are common, and there is a 
marked tendency to uraemia. 

II. Chronic Interstitial is insidious. It is most common in old and 
gouty subjects, and is attended with changes in the arterial system. Dropsy 
is late. The urine is copious and pale, with but little albumen and few 
Hyaline casts. Inflammatory complications are not so common. Duration 
is very long. 

III. Amyloid Degeneration follows Syphilis, etc., and is associated 
with Amyloid liver, etc. The urine is moderately abundant, with a mode- 
rate amount of albumen, casts, etc. Dropsy is early and extensive. Duration 
is less than in interstitial, greater than in the catarrhal form. Persons of 
Gouty Diathesis, with tense radials and a marked accentuation of the first 
sound, accompanied by a tendency to Polyuria, and who are liable to dis- 
turbances of breathing, should be suspected of nephritis. This is known as 
the pre-albuminuric stage. 

Prognosis in both forms, whether acute or chronic, is difficult. 

I. The worst Acute cases may recover absolutely. 

Unfavorable symptoms are — i. A sudden onset. 2. Previous ill con- 
dition. 3. Scanty urine. 4. Copious Albumen and tube casts. 5. Rapid 
Dropsy. 6. The occurrence of inflammatory symptoms. This form is more 
favorable after scarlet fever than when idiopathic. 

II. Of Chronic forms, Amyloid is always fatal. In advanced Interstitial, 
cure is impossible and death is inevitable. In the early stage, life may be 
prolonged by treatment for some time. In Chronic Catarrhal the Prognosis 
is most hopeful ; even after years the Kidney may become useful. Marked 
Cardiac or nervous derangement, Persistent Dyspnoea or dropsy, or Decrease 
in urine indicate the fatal termination. 

Treatment of Acute and Chronic Nephritis. 

I. Acute. Maintain the skin in an active and perfect condition. 
Confine the person to bed, and secure good ventilation, clothing, etc. The 



66 

diet must be restricted and no stimulants be allowed. Keep the bowels open 
by the use of laxatives, as Bitartrate of Potash, Epsom Salts, etc., in mild 
but sufficient doses to secure one or two stools per day. In the early stages, 
when there is fever, we may give Calomel, Ipecac, and Digitalis, thus obtain- 
ing a double result. Digitalis is a non-irritant diuretic. It may be given in 
small doses at short intervals. For activity of the skin, vapor baths or the 
cautious use of Jaborandi, or hypodermic injections of Pilocarpin are indi- 
cated. Where the nervous symptoms are urgent, stronger laxatives and 
purgatives. After sweating is set up we may apply cups over the region of 
the kidney, followed by the application of hot sand-bags. This causes a 
slight irritation. Blisters must not be used. Opiates must be avoided, as 
they dry the skin and lessen the urinary secretion. Where sedatives are 
absolutely necessary, use Chloral and Bromide of Potassium. Chloral by 
enema is of great value where there is a tendency to uraemia and where the 
stomach is non-retentive. Gr. x to xv in aquae fjfij act very powerfully, 
especially in the uraemia of child-birth. 

II. Chronic. Climate is of the greatest importance. It should be mild 
and not changeable. Whether it is moist or dry it is of not much moment. 
If possible secure pure spring water with small proportions of mild salines, 
especially Ferruginous salines. The body clothing is of more importance than 
in Phthisis. Personal hygiene is absolutely essential. We should recommend 
dry friction, warm baths with a cold douche, Turkish baths, or inunctions, 
according to the patient's condition. The diet must be conducted on scien- 
tific principles. Milk is a diuretic, and must always be used, whether in the 
form of pure milk or skimmed, whey or rennet, will depend on the digestive 
capacity. If it is not well borne, a more mixed diet is indicated, e. g., of 
lean meat, either broiled or minced, with a small amount of vegetable mat- 
ter. Others do best on cereals with the addition of a little fruit and milk. 
The free use of pure spring water is an essential. 

V. Hsematuria. Blood may occur in the urine in any amount from a 
mere trace to pure blood. The urine may only be smoky from its presence 
or it may occur in clots. Microscopically, the corpuscles are seen to be 
shrunken from contact with the urine. With these may be blood casts and 
fibrin. 

Causes, i. It is a symptom of severe congestion of the Kidney. 
2. In Acute Bright's Disease it is in small quantity and is mixed with tube 
casts. 3. The blood may come only from the Bladder, either from the 
presence of Calculi, or from a hemorrhoidal or varicose state of the vesical 
veins. This latter, though lasting for many years, may not injure the 
health. We have descriptive evidences of Cystic irritation, but sounding 
gives no results. In the absence of Bright's disease there are no tube casts. 
4. Cancer or Vascular Polypi. 5. Renal Calculi. Here the urine is 
often copious. 6. It may be endemic from the entrance of a parasite 
through water. 7. It may arise in the course of Malaria, Yellow fever 
and Typhus, especially in the Hemorrhagic form. It occurs very fre- 
quently in Malarial districts. 

Prognosis depends upon the cause. 

Treatment is that of the cause. Where it is abundant give full doses of 
Quinine, especially when it is paroxysmal. Other drugs, as Gallic Acid, 
Ergot, Erigeron, Sulphate of Iron may be used. When it comes from the 
Bladder combine with local measures, such as ice bladders over the pubes, 
enemas of very cold water and suppositories of ice in the rectum. Astringent 
injections are bad in all but very severe cases. 



6 9 

VI. Haemoglobinuria, or Hsematinuria. Here blood corpuscles are 
not found in the urine, but the envelopes of the corpuscles are seen. Spec- 
trum Analysis reveals hsemaglobin. 

Cause. It may arise from the rapid absorption of a clot in extra- 
uterine foetation, or in the course of poisoning by Arsenic and Carbonic 
Acid. It is rare in simple congestion. 

Symptoms. It is paroxysmal and returns at irregular intervals. It is 
especially noted in Malarial districts, though the patient may not previously 
have shown any malarial symptoms. 

Its Pathology is obscure. There is no known or recognizable cause for 
the blood. It is connected in many cases with malarial toxaemia; in others 
with neurosis of the ganglia of the Kidney. 

Treatment. Extreme attention must be paid to personal hygiene. Avoid 
chilling of the surface and nervous exhaustion. Travel and change of resi- 
dence may be required. Quinine in large doses exerts a beneficial influence. 

VII. Chyluria, or Lymphangioma of the Bladder is very rare. The 
urine is milky, and under the microscope fat globules appear. It is met with 
in tropical countries and is due to the presence of a parasite. 

VIII. Morbid Growths of the Kidney. 

i. Hydronephrosis. Here we have the formation of a Cyst. The 
weight of the Kidney may be increased to seventeen pounds. 

Causes, i Obstruction of the ureter, e. g., by a calculus. 2. Degen- 
eration of the substance of the Kidney with obstruction of the tubules. 
This is very often seen in interstitial nephritis. 

Symptoms, if only one Kidney is involved, are very obscure. By deep 
palpation, a tumor in the renal region is recognized, extending outwards 
and forwards and not movable. On turning the patient the area of renal 
dullness is increased, and if the tumor be very large we may obtain 
fluctuation. 

Diagnosis. If it is near the surface, on the introduction of an explora- 
tory needle, we obtain fluid, containing salts of urine. Pressure on the non- 
affected ureter will show no urine entering the bladder from the affected side. 

Treatment. On recognizing the condition, remove the Kidney, or only 
the calculus if the Kidney structure is not too much disintegrated. 

II. Renal Cancer. Primary is not rare, but is more common in chil- 
dren. We find Carcinoma, or round-cell Sarcoma. 

Symptoms. After a period of apparently unintelligible distress, enlarge- 
ment of the abdomen takes place. The tumor does not fluctuate, though it 
may seem to do so. The urine is often unchanged. It may contain a little 
blood from time to time and disintegrated cells of indefinite shape. Another 
part of the Kidney may be affected by Bright' s Disease and then there is 
albuminuria. 

Diagnosis is based on — 1. The presence and character of the tumor. 2. 
The progressive failure of general health; and, 3. The absence of liquid on 
tapping. 

III. Perinephritis is where there is an inflammation of the outer surface 
of the Kidney going on to the formation of an abscess. It may be traumatic 
or attend upon Scrofulosis. 

Symptoms are obscure. In the early stage it may simulate incipient 
spine disease. The patient holds himself erect and stiff and has pain on 
movement. This is accompanied with febrile action and failure of health. 
Later on we have hectic fever. 

Diagnosis is made by exploratory puncture. 

Treatment consists in incision and drainage. 



III. DISEASES OF THE HEART. 

I. Pericarditis. The pericardium is subject to — i. Inflammation, 
which may be Acute or Chronic. 2. Effusions, not the result of inflam- 
mation. 3. Gaseous accumulation, or Pneumocardium, which is rare; 
and 4. Growths, which also are rare. 

Causes of Pericarditis are — 1. Cold, etc. 2. Extension of inflam- 
mation, from — (a) The Pleura, (b) the Heart itself. 3. Wounds, (a) 
Punctured, (b) Contused, and (c) from fractures. 4. Rheumatism ; but 
this is not so common a cause as in endocarditis. 5. Bright' s disease. 
6. Septic dseases. 

Symptoms. There is — 1. Pain and tenderness, referred to the region 
of the heart. 2. Fever, with rapid irritated pulse. 3. Short dry cough, 
which is sympathetic. 4. Friction sound over the heart, which keeps 
time with the beat. This sound is superficial, has no relation to breathing, 
and continues if the patient holds his breath. 5. There is no change in 
the area of dullness. 6. There is an absence of Pulmonary symp- 
toms to explain this condition, except when the disease 'is secondary to 
pathological changes elsewhere. 

When the Effusion takes place, the friction sound disappears. The apex 
rises, and this is followed by a weakening, or entire absence of the apex 
beat. Cardiac dullness is broader at the base. It assumes a rude tri- 
angular area, with the base downwards, extending to the fourth intercostal 
space on the right side, and further than normal to the left. Cardiac 
Murmur is weak, and may be lost. A prominence over the heart is 
observed. The Fever continues. The Pulse is rapid, soft and weak. 
The Breathing is disordered, and frequently we have Orthopncea. The 
vessels of the neck are distended. The short, dry cough continues, 
and there is a feeling of weight, distress, and frequently pain over the 
chest. The lungs may be secondarily engorged. The Effusion may consist 
of serum and lymph ; or there may be pus from the commencement ; or, 
again, the serum may become purulent. 

Terminations. 1. The serum may be absorbed, the lymph organizing. 
2. The condition may become chronic ; or 3. May result fatally from cardiac 
obstruction or failure. 

Chronic Pericarditis. Causes. 1. It may follow an acute case. 

2. It may be chronic from the start, especially when there is a large amount 
of lymph present ; also, when the Effusion is purulent, owing to a depraved 
condition of the person, or when there is a latent condition, as in pleuritis. 

3. The occurrence of acute attacks. 

Symptoms are — 1. Fever, often hectic in character. 2. The Pulse 
is rapid, soft and weak, especially in acute cases ; but it may be less rapid 
than, or even, normal. 3. There is Orthopncea. 4. Cough continues. 
5. Expectoration may result from secondary Pulmonary congestion. 6. 
Pain, or, at least, distress about the heart. 7. The strength fails, and 
the patient is weak. 8. The physical signs continue the same. In favorable 
cases, there is left an adherent pericardium. The adhesions may be partial 
or complete, either soft and cartilaginous or calcareous. 

Symptoms of Adherent Pericardium. The heart's action is frequent 
and easily disturbed. The breathing is sympathetically altered. There is a 
vague feeling of pain and soreness about the heart. 

Physical Signs. 1. The area of dullness may or may not be in- 
creased. 2. The cardiac impulse is extended, weak and wavy. 3. There may 
be a retraction of the intercostal space over the apex beat. 4. Fremitus 



73 

and thrill are sometimes felt. 5. The heart sounds may be normal 
or weakened. 6. Friction sound is usually wanting. 7. We notice the 
absence of valvular trouble, the existence of which would account for 
these symptoms Myocarditis may result from Pericarditis. The amount of 
fluid may be a quart. The presence of four to six ounces of clear serum 
with a normal pericardium is not pathological. If the Effusion is large it is 
likely to be purulent. 

The Diagnosis consists in recognizing — 1. The existence of the condi- 
tion. 2. The Character and extent of the Effusion. In Pleurisy the pain 
is different and the friction sound is not cardiac in rhythm. By an exocar- 
dial friction sound we understand a pleuritic friction of cardiac rhythm. 
We have a pleurisy of the inner side of the lung against which the heart 
rubs. 

As to the Character of the Effusion, we are guided by — 1. Cause and 
duration. 2. The variety of the symptoms. 3. The result of exploratory 
puncture. 

The Prognosis of Acute is generally favorable, of Chro?iic grave, and of 
Adherent pericardium uncertain. It is not usually grave, but when the 
heart itself is involved, it may be so. 

Treatment. 1. Of the Acute Stage. Enforce Absolute rest and strict 
diet. Apply a blister over the prsecordia, moderate in size and action. 
Give Calomel, Opium and Digitalis in doses varying with the severity of the 
case and age of the patient, together with quinine in full doses. 2. After 
the Acute stage keep the patient quiet in bed for a long time, and give 
Iodide of Potassium and Digitalis. 3. Of Chronic Pericarditis with 
Effusion. If the effusion is serous and not of great extent insist on rigid 
hygiene and strict diet. Order repeated blisterings and jaborandi. Put the 
patient on the use of Potassium Iodide and Alkaline treatment. Calomel, 
Squill and Digitalis may also be given. If the Effusion is extensive and is 
dangerous to life, or if it has lasted a long time and the symptoms point to 
its being purulent, the case becomes one for operation. This is performed 
either by incision or puncture at the lower border of the fifth rib. We 
should first make an exploratory puncture with a small needle, and then use 
the aspirator. If Pus is found the opening should be enlarged, and where it 
is offensive the sack should be washed out. The sack should then be closed 
up with the exception of a small hole. Where the sack is very large it may 
sometimes be necessary to resect a portion of a rib, in order to allow of 
adequate pressure being made upon it. 

(For Pneumothorax, see Diseases of the Respiratory System, Part II.) 

Hypertrophy of the Heart may be considered under the three forms : 
Simple, Eccentric and Concentric. In Simple the walls are thickened, 
while the cavities remain normal. In Eccentric, or hypertrophy with 
Dilatation, the walls are thickened and the cavities are enlarged. Concen- 
tric does exist, but is so rare that it may, practically, be disregarded. In 
this form the walls are thick and the cavities contracted. 

By Dilatation of the heart we understand an enlargement of the cavities 
with a thinning of their walls. The right ventricle is more often subject to 
simple dilatation, while the left is more frequently liable to eccentric hyper- 
trophy. 

Appearance of the Cardiac Muscle : Where dilatation is excessive or has 
lasted a long time the color of the muscle is pale, or is tinged with yellow. 
The muscles finally become soft and subject to fatty Degeneration. 

Causes of Hypertrophy are — 1. Prolonged and excessive exertion. 
2. Obstructions to the circulation at a distance from the heart, thus giving 



74 

rise to affections of the valves. 3. Atheroma and Fibrosis of the Capillary 
Walls. 3. Cirrhosis of various organs. 

Symptoms of Simple Hypertrophy — 1. Overaction of the heart. 
The impulse is too strong and more extended than normal. There is a 
throbbing at the praecordia and throughout the system. 2. The Pulse is 
tense, large and strong. It may be normal or accelerated. 3. Exertion 
causes the arteries of the neck to throb. There is a disposition to a 
flow of blood to the head and to nose bleed. The Complexion is florid 
and Dyspnoea follows exertion. The first sound of the heart is pro- 
longed and dull, while the second is accentuated. 

The Prognosis is good at first, but the heart finally becomes weak, and 
then we have the following symptoms : 1. An extended heaving impulse 
and an increase in the area of cardiac dullness. 2. There is a sense 
of weight about the chest, and dyspnoea is usual. Palpitation follows 
any exertion, and the patient is soon tired out. The face becomes pale 
and the extremities are easily cyanosed. The first sound is feeble, and 
murmurs are apt to develop. The pulse is large and compressible, but 
not strong. Progressive failure of the heart's power is shown by conges- 
tions and dropsy. 

In Eccentric Dilatation we have a failure of the circulation and pallor 
of the surface of the body, with a tendency to venous congestion, lungs, and 
extremities, producing dropsy. Palpitation and dyspnoea are readily excited 
and there is a feeling of distress about the praecordia. The pulse is small 
and rapid. 

Physical Signs. The praecordia is prominent and apex impulse ex- 
panded. Normally, it is one inch in diameter, but may be expanded over 
the whole praecordia, and its pulsation be visible over the abdomen. The 
apex beat, if the left cavities share in the involvement, is displaced down- 
ward and to the left. If the right cavities alone are affected, it is displaced 
to the right. In simple hypertrophy, the impulse of the heart is hard, but 
where there is dilatation we feel a wavy undulating tremor. 

Percussion reveals an increased area of cardiac dullness. 

Auscultation. In simple hypertrophy the first sound is prolonged and 
heavy, the second is accentuated. In simple dilatation the first is heavy and 
booming, and the second is accentuated. Where, however, there is much 
dilatation, the first sound is short and sharp, somewhat like the normal ; 
while the second sound remains unchanged. 

Diagnosis. In both pericardial effusion and dilatation the praecordia is 
prominent and the area of dullness is increased ; but in effusion the apex is 
raised and its impulse weak or absent ; while in dilatation it is found at the 
lowest point of dullness, and its impulse is extended and heaving. Again, in 
pericardial effusion the heart sounds are normal, but are obscure and heard 
high up ; whereas in hypertrophy they are low down and abnormal. 

The Prognosis depends upon — 1. The relation of dilatation and hyper- 
trophy. 2. The condition of the valves. 3. The co-existence, or otherwise, 
of chronic renal disease. 

Treatment is carried out chiefly by attention to regimen and diet, and 
to the regulation of the habits. 1. In simple hypertrophy, uncomplicated by 
renal disease, a restrictive diet is necessary, and the patient carefully guarded 
against over-exertion and excitement. With this we combine the prolonged 
use of Aconite and Bromide of Potassium. If co-existent with this we have 
a rheumatic diathesis, long courses of Lithium and Potassium Iodide are 
further indicated. 2. In Marked Eccentric Hypertrophy, i. e., hypertrophy 
with dilatation, still more care is needed with reference to the habits and 



77 

diet. Special attention must be paid to all the secretions of the body, and 
the slightest tendency to congestion removed. When the heart power begins 
to fail, cardiac sedatives become less useful, and digitalis is indicated. To 
give tone to the system put the patient on prolonged courses of strychnia 
and arsenic. Rheumatism and Bright's Disease must be treated when they 
arise. 3. The treatment in Extreme Dilatation is merely palliative. There 
is a tendency to congestion of the stomach and liver, hence Digitalis and 
Strychnia may be given. Where the distress is excessive we are compelled 
to have recourse to opium, either in the form of suppositories or hypodermic 
injections. 

Fatty Degeneration may attack either an hypertrophied or a normal 
heart. We must distinguish between the envelopment of the heart by a 
fatty deposit, which is usually a part of Polysarca (1. e., a tendency to the 
deposit of fat), or fatty infiltration ; and fatty Degeneration, in which we 
have a true degeneration of the heart muscle. When it comes on as a 
primary disease it is hard to recognize. 

Causes are — 1. Profound failure of nutrition. 2. Nervous strain. 

3. Excessive exertion. 4. Disease of the coronary arteries ; and 5. 
Alcoholic excesses. 

Symptoms. Exertion induces dyspnoea, which may resemble spells of 
Asthma. The patient becomes dizzy on suddenly changing his position. 
The surface of the body and face are pale. On examination the pulse is 
found to be small, soft and feeble. It is extremely weak and easily affected 
by exertion. It may be either abnormally slow or fast. The first sound 
of the heart is weak and fading, and the cardiac impulse extremely feeble. 
There is a tendency to syncope and pulmonary congestion. As the 
disease progresses CEdema of the feet, and finally general dropsy ensue. 
The kidneys are also affected. The appearance of fatty degeneration in 
the layers of the cornea is frequent and gives rise to the condition of the eye 
known as "Arcus Senilis." 

The Prognosis is always unfavorable, although the disease may last 
from one to several years, patients being frequently confined constantly to 
their chair. Sudden death is apt to follow on exertion. 

The Diagnosis, if there has been hypertrophy, is made by the occurrence 
of heart failure. If the heart has been otherwise normal, the occurrence of 
cardiac weakness without any apparent cause to account for it, the presence 
of "Arcus Senilis," and the history of a probable cause, should make us 
think of fatty degeneration. It is not wise to mention fatty heart to pa- 
tients until the disease has advanced so far that it is absolutely necessary to 
tell them. The symptoms may arise from temporary nerve or muscular 
weakness. We should remember that the diagnosis is based upon reasoning, 
and not upon physical signs. Hence as physicians we should be cautious 
about expressing our opinion. 

The Treatment is merely palliative. Strict attention must be paid to 
the diet and regimen. The greatest caution must be observed in making 
any exertion. In the way of drugs we need muscular and cardiac tonics, 
and alcoholic or diffusible stimulants in small and weak doses. 

Angina Pectoris. This is an affection characterized by paroxysms of 
pain in the cardiac region, which usually extend into the left arm, and are 
attended with a feeling of impending death, and in which sudden death does 
sometimes ensue. Anginoid Pains may occur — 1. In Hysteria. 2. As a 
part of Gastralgia. 3. From heart strain in gouty or neuralgic persons. 

4. From ovarian trouble in nervous women ; and 5. From the use of 
tobacco, coffee, etc. These pains, however, are more radiating and last 



78 

longer than those of true Angina. Tney are not so intense, and are more 
directly connected with the palpable cause. They do not usually pass down 
the left arm and cause numbness, nor do they bring about the horrible feeling 
of impending death which is characteristic of Angina. 

True Angina. The paroxysm comes on abruptly, it may be during 
sleep, with an agonizing pain about the praecordia, which extends under the 
sternum and down the left arm, causing numbness and tingling and an 
inability to move the arm. The breathing is imperfect, the pupils dilated, 
the surface and face cold and pale. Patients clutch at the heart, fall back, 
and are unable to speak. The pulse is found to be weak and soft, and a 
difference is observed between the right and left radials. An attack may 
last from one second to several minutes, leaving the patient weak or dead. 
Patients commonly die in the first attack. 

Causes, i. Digestive disturbances in a person with heart disease. 2. 
Excitement, over-exertion and exhaustion. 3. The use of tobacco. 

Another Form of Anginoid Pain arises in connection with a neuralgia 
of the cardiac plexus. It is undecided whether this is accompanied by a 
spasm or paralysis of the heart muscle. The latter is probably the most 
usual. The sense of constriction would seem to point to spasm; but on 
post-mortem examination, the heart is usually found to be dilated. The 
pains are induced by exertion. They grow in intensity, and extend in the 
same direction as those in the true form. Patients may have these attacks 
without exertion. They generally run into true Angina. 

Causes are — 1. Atheroma of the coronary arteries, preventing the heart 
from getting a full supply of nourishment. 2. Valvular diseases, e. g., 
lesions of the aortic walls and valves. 3. Changes in the walls of the heart. 
These are Mechanical. There are also Functional causes. 

Prognosis, when due to functional causes, is good. When organic 
disease is at the bottom, it is bad. When it is accompanied with the ap- 
pearance of " Arcus senilis," it is always fatal. 

The Treatment. We must study the character of the patient, of the 
attacks, and of the cause. When it arises from over-exertion, prolonged rest 
in bed for a couple of months is often attended with good results. As 
remedies to prevent the spells, long courses of Arsenic, with or without 
Quinine and Strychnia, are useful. If the patient is anaemic, Iron must be 
added. For Gouty patients, Iodide of Potassium and Lithia are indicated. 
Valerian and the Bromides are not so good as Nitro-glycerine and Nitrite of 
Amyl given continuously. Patients should carry Nitrite of Amyl always 
with them in five-drop bottles with rubber corks ; and this should be waved 
in front of the nose when a spell come on. This may break up the tendency 
to other attacks. When taken often, however, it loses its effects. Counter 
irritation may be applied at short intervals over the prsecordia by means of 
blisters or the actual cautery. Particular attention must be paid to diet. 

Palpitation is a functional condition of the heart, brought about by 
irritation of the cardiac nerves, leading to irregular action. 

Causes. 1. All wearying anxieties and exhaustions. 2. Exciting occu- 
pations, frights, etc. 3. Reflex irritation, whether sexual or stomachic. 4. 
Causes which induce anaemia, particularly in nervous subjects. 5. The use 
of substances which directly affect the heart, e. g., tobacco, tea, and coffee 
in excess. 

Symptoms. There is distress about the praecordia, greater than that 
which those suffering from organic disease experience. There are sensations 
of weakness, giddiness, etc., and excessive hypochondriasis. 



8i 

Physical Signs. The action of the heart and pulse is strong, but both 
are irregular. The apex beat is diffused. This irregularity may be contin- 
uous or in paroxysms. The number of beats may be as high as 250, or the 
pulse may be intermittent. The Heart Sounds are confused. The first 
sound is less muscular and more valve-like, or there may be a functional 
murmur which disappears after the paroxysm. 

Diagnosis. There is no difficulty in distinguishing it from organic dis- 
ease, except in those rare cases where a murmur exists. The heart must be 
examined several times during the day and when the patient is most tranquil. 
We base our diagnosis on the absence of disturbances of circulation and 
respiration, and of cardiac enlargement, and also on the history of the case. 

Treatment. The cause must be discovered and removed, e.g., rapid 
eating, or improper mastication of the food. The excessive use of tobacco, 
tea, coffee, etc., must be prohibited, and any cause of reflex irritation re- 
moved. Moral suasion plays a very important part. If no good effects 
follow the above, we may try the use of Bromides, with or without Digitalis, 
or Belladonna, Hydrocyanic acid, and Aconite according as they are well 
borne and do good. Courses of Iron, Arsenic, Quinina, and the Hypophos- 
phites are often serviceable. This Treatment includes that of Irritable 
heart which is produced by excessive strain and is often found in recruits, 
athletics, etc. 

Endocarditis is Acute and Chronic. Under the head of Acute we con- 
sider Simple, Rheumatic and Septic. Chronic Endocarditis may be Second- 
ary or Ulcerative. 

Anatomical Conditions. In the acute stage we find a congestion and 
a cloudy swelling of the membrane, with slight roughness, followed by a 
proliferation with the formation of nodules. Instead of the vegetations be- 
ing on the surface, they may be under the membrane, and give rise to thick- 
ening and opacities. As the result of these processes we find — 1. Obstruc- 
ting of the orifices. 2. Insufficiency of the valves; or 3. They may be 
only roughened. 

Causes of Endocarditis. I. Acute. It may be — 1. Idiopathic; or 
2. Occur in the course of acute diseases, e. g., Rheumatism, Scarlet Fever, 
Diphtheria, Measles and Small Pox. 3. It may be set up by septic or by 
pyaemic processes. 

II. Chronic Endocarditis — t. As a rule follows the acute. 2. It may 
be sub-acute or chronic from the start, especially in those of a gouty 
diathesis. 3. It may be produced by changes of an atheromatous nature. 

I. Symptoms of Acute Endocarditis. 1. Ordinary Endocarditis 
usually occurs in the course of some acute disease. Idiopathic cases are rare. 
We have a rise of temperature which cannot be explained on any other ground. 
The Pulse is rapid and there is pain and tenderness over the heart. The 
murmur is soft and not very intense or extended. If the attack is severe we 
may have a disturbance of breathing, sometimes amounting to orthopncea. 
When it comes on in health its onset is marked by rigor, fever, etc., and the 
same physical signs as above. 

The Course is uncertain, generally from seven to ten days, but there is 
a great tendency to become chronic, the overaction of the heart and the 
murmur continuing after the other symptoms have disappeared. 

Prognosis, if it is recognized and treated, is good for immediate recovery, 
but bad as regards a permanent cure. 

The Diagnosis is easy, if we think of examining the heart. In young 
children it is apt to be overlooked. 



82 

Treatment. Rigid rest and protection of the body, especially in persons 
of a gouty diathesis. Counter irritation by means of blisters over the heart 
from time to time. This, however, must not be attempted in scarlet fever 
or measles. As drugs, Potassium iodide and Digitalis are required. 

2. In Ulcerative Endocarditis the valve is softened and ulceration of 
the endocardium takes place, sometimes followed by perforation. 

Causes. It may attack a previously healthy heart, owing to depraved 
nutrition or to septic causes. It may occur in a diseased heart. 

The Symptoms are those of severe endocarditis, greatly exaggerated. 
The fever soon assumes a remittent type. The skin is sallow. The breath 
emits a sweet or pygemic odor. A Typhoid condition may ensue. This 
disease is accompanied by irritation of distant organs. The spleen may 
become large and tender. The Kidneys show evidences of Bright' s Disease. 
The lungs exhibits spots of inflammation, due to the deposition of particles 
brought away from the heart. 

Prognosis. It is usually fatal. The patient may be carried off within 
a few weeks or last a couple of months. 

Diagnosis. It is important to recognize the ulcerative character of the 
condition. This is done, not by the physical, but by the constitutional 
signs, and by the failure of our treatment to bring about a good result. 

Embolism is rare, but may be brought about by the detachment of little 
particles of vegetations from the valves. These set up metastatic abscesses 
elsewhere, the symptoms being those of ulcerative endocarditis. 

Treatment should be supporting and symptomatic. 

Prognosis is very bad, unless the patient has a rugged constitution and 
can withstand the drain upon his system, thus set up. 

II. Chronic Endocarditis is synonomous with organic disease of the 
heart or valvular disease. Location. — But one valve may be affected or all 
three. The mitral valve is more frequently attacked. In the order of fre- 
quency we find — i. Mitral regurgitation. 2. Aortic stenosis and insuffi- 
ciency. 3. Mitral stenosis, which may exist alone, but is rare. 4. Tricuspid 
regurgitation. 5. Lastly, the Pulmonary artery may be affected owing to 
intra-uterine life. 

Symptoms are General and Local. I. General : Disordered action is 
almost universal, but in some cases of severe disease the heart may be regular. 
The rhythm is changed. The irregularity may be in the force of the beats 
or in the time, or there may be intermissions. At times this irregularity is 
very great. When the mitral and tricuspid valves are affected, we find a 
continued irregularity of action. The pulse may vary from the heart, there 
being two or more beats of the ventricle to one pulse-wave. Hence it is 
important to count both the heart and pulse. The latter may be described 
as "jerky," "sledge-hammer," "cut-off." The arteries are apt to be 
atheromatous, and this, in many cases, may lead us to think the pulse is 
harder than it really is. The superficial circulation is affected, the eye 
is prominent and full, the capillaries injected, and the extremities are blue. 
Other organs are affected. 1. The Lungs are often congested. The 
breathing is accellerated, especially on exertion, and bronchitic rales are 
heard posteriorly. 2. The Liver and Stomach suffer. Gastro-hepatic 
congestion is frequent, and there is often a marked tendency to biliousness. 
Diarrhoea is frequent, and there is a tendency to formation of hemorrhoids, 
which often bleed. 3. The effect on the Kidney is shown by a tendency 
to frequent urination and by the presence of albumen in the urine. There is 
a great liability to nephritis. 4. The Spleen is often enlarged and swollen. 
These conditions become more marked as the propelling power of the heart 



35 

decreases. In the last stage Propsy makes its appearance in the feet. This 
is most marked toward the close of the day. The legs gradually become 
(Edematous as the heart fails, then the scrotum and abdomen, and finally the 
cavities of the body. The worst cases are those in which the tricuspid and 
mitral valves are affected. 

Physical Signs of the Various Lesions : — 

Mitral Regurgitation. A Systolic murmur over the mitral 

area. 
Mitral Stenosis. A pre-systolic murmur over the body of 

the heart nearer the apex and carried far to the left. 
Aortic Regurgitation. A Diastolic murmur starting from 
the base of the heart and carried up along the aorta into 
the carotid artery. 
Aortic Stenosis. A systolic murmur over the same area. 
Tricuspid Regurgitation. A systolic murmur heard over 
the right ventricle at the epigastrium and low down to 
the- right of the sternum. 
Tricuspid Stenosis is so rare that it need not be considered. 
Mitral Regurgitation is connected with Simple or Eccentric Hyper- 
trophy and with a dilatation of the left auricle. Mitral Stenosis, with great 
enlargement and Hypertrophy of the left auricle. Both Aortic Regurgita- 
tion and Stenosis give rise to eccentric Hypertrophy. 

Diagnosis is made by observing — i. The time when the sound is pro- 
duced. The radial must be noted at the same time as the heart. 2. The 
area of dullness, i. e., the effect of the disease on the size of the heart. 3. 
Whether there is hypertrophy or dilatation. This is shown (a) by the 
character of the impulse, (b) the force of the beat, and (c) the effect on the 
general circulation. 4. Notice the direction of the transmission of the 
sound; and 5. The relation which the murmur bears to the time of the 
normal heart sounds. 

Symptoms of Tricuspid Regurgitation. We find — 1. Marked 
changes in the right ventricle, Dilatation, and perhaps Hypertrophy. 2. 
Pulsation of the veins of the neck from meeting with the blood from the de- 
scending vena cava. 3. Pulsation of the liver from the shock caused by the 
meeting of the arterial with the blood from the descending vena cava. 

Pulmonary Stenosis is very rare. It is generally congenital. The 
right ventricle after birth being the most active part of the heart, the changes- 
in the arterial system which should take place at birth are interfered with, and 
cyanosis occurs. This at times is excessive, and great difficulty is experienced 
in keeping the patient warm. There is a great liability to collapse and pul- 
monary congestion. Patients rarely attain to adult life. Most frequently 
death occurs soon after birth. Where life is unfortunately prolonged, such 
patients are puny, ill-nourished and weak. The lips and extremities are 
purple, the fingers clubbed. In such cases we find a systolic murmur 
originating at the base of the heart and carried upwards to the left along the 
pulmonary artery. It is irregular as to its area, frequency, etc., and we 
make our diagnosis by the more evident general symptoms. 
Complications of Chronic Valvular Disease. 

I. Dropsy is common, and is due to the extreme venous congestion. 
It may appear in the chest before it occurs elsewhere, this being due to 
some local cause, as the pressure of an enlarged heart upon an Azygos vein. 

II. Hemorrhage, which is most commonly Bronchial. It is chiefly 
found in Mitral Obstruction. As Results of Hemorrhage, we may have 
Pulmonary irifarction or Thrombosis. Epistaxis is often frequent, and may 



86 

l>e almost uncontrollable. Bleeding Piles are not rare. Apoplexy may 
occur. 

III. Paralysis may result from vegetations of the valves being carried 
off as emboli. 

IV. As the result of Cardiac disease, Embolism may give rise to Gan- 
grene. 

Prognosis. A double valvular lesion is more unfavorable than a single 
one. The occurrence of Dilatation in place of, or out of proportion to, the 
Hypertrophy is bad. When it develops rapidly, and the heart does not 
respond quickly, it is a bad sign. The existence of rigid arteries, " Arcus 
Senilis," or previous ill nutrition, renders the prognosis unfavorable. In 
persons of strongly rheumatic diathesis, or where a complication of Kidney 
affections exist, it is bad. 

Treatment. I. General Principles. Rest is absolutely necessary in 
order to reduce the strain upon the heart. It is not wise to endeavor to 
bring up the heart to the full work of the system ; but we should rather 
endeavor to bring the amount of work within the power of the heart. If 
possible, the patient should lie down for a greater part of the twenty-four 
hours. All strains upon the arterial system must be avoided, such as those 
caused — i. By going up hill or up stairs. 2. By the contraction of the 
capillaries of the surface, as the result of chills; or, 3. By the congestions 
of internal organs, etc. 

II. Medicines : Digitalis, Belladonna, Convallaria, the Bromides, Aco- 
nite and Veratrum Viride will be considered in detail, the latter being less 
frequently indicated than in the acute. 

1. Digitalis regulates, slows and strengthens the heart. No injurious 
effects result from its accumulation. It does not rapidly lose its effects, 
and it may be used for years. The best preparation is the tincture. A 
good infusion is reliable, but inconvenient to administer. Digitalin is often 
a convenient form of administration. We should begin with small doses, as 
it sometimes irritates the stomach. When this is the case abandon its use 
or change the form of administration. 

2. Belladonna is good where the action of the heart is irregular and 
rapid from some reflex cause, e. g., the stomach. It does not increase the 
heart's force. 

3. Convallaria is inferior to Digitalis in range and certainty, and is 
disagreeable to the taste and to the stomach. It may be used where Digitalis 
fails, and where there is a tendency to dropsy, as it is a Diuretic. Long 
courses do no harm. The dose of the fluid extract is gtt v-vii ter die. 

4. The Bromides are useful where there is irritation, irregularity, and 
excitement, but where there is little or no organic lesion. They must not 
be pushed for too long a time, as they lower digestion and the tone of the 
system. 

5. Aconite ; and, 6. Veratrum Viride, are indicated where there is 
simple hypertrophy which is too great for the lesion of the valves. Small 
doses may be given, extending over a long period of time. 

Treatment of Special Symptoms. For Dyspepsia and Kidney 
trouble improve the general health by tonics, vegetable bitters, and iron. 
Where the stomach is irritable, hydrocyanic acid, bismuth, and Argentic 
Nitrate lessen the irritability of the stomach and consequently of the heart. 
In venous congestion of the liver, especially with oedema, restrict the 
diet and give small doses of blue mass, together with the use of mineral acids. 
In cases associated with Rheumatism order prolonged courses of Potassium 
Iodide and Alkalies in small doses. Cardiac Dropsy indicates that the 



§9 

heart is weak or that some organ is obstructed. Enjoin rest in bed and 
study the cause. 

Diseases of the Great Vessels. The arteries are subject to — i. In- 
flammation or Arteritis. 2. Degeneration or Atheroma. 3. Aneurism. 
4. Narrowing or Occlusion. 

Aneurism may arise from — 1. An injury to the coats of the vessels. 2. 
Previous syphilitic Arteritis. 3. Chronic Atheroma forming an atheromatous 
ulcer. 

Termination. 1. It ruptures either from chafing against some hard sub- 
stance, or its walls may become so attenuated that it bursts from blood pres- 
sure. 2. It heals by clotting, owing to the coagulation caused by the slowing 
of the current from pressure. 

Thoracic Aneurism. Symptoms. Deglutition is impaired. A 
pulsating tumor, or a thrill is apparent. There is dullness on percussion 
over the point of contact of the aneurism with the chest wall. An aneurys- 
mal murmur may be heard or the heart sounds be changed. There may be 
a prominence or bulging of the ribs. 

Aneurism of Abdominal Aorta. We may often feel the tumor. 
There is a prominence either anteriorly or posteriorly, but percussion may 
not show dullness on account of the tympany of the ribs. None of these 
symptoms may be present if the aneurism be small or deeply situated. This 
is especially true of small aneurisms in the thorax. 

Peculiar Symptoms. There is Pain referred to the spot of pressure, 
or it may radiate along the nerve pressed upon. If very severe, Paralysis 
may occur, e. g., Aphonia from pressure on the recurrent laryngeal. The 
Pupils may be unequally dilated. If it is situated in the abdomen it may 
press upon the abdominal sympathetics, and profuse sweating of one or 
both sides be produced, the intestinal secretions being modified. When 
situated on the abdominal Aorta it seldom presses on anything else than the 
nerves. Previous to the rupture of these aneurisms, a valve may be formed 
which allows a leakage to take place for some time before the final opening. 
Paralysis may result from the erosion of the spinal cord, or asphyxia, or 
starvation from pressure on the CEsophagus. 

Prognosis depends on — 1. The patient's age. 2. The state of the 
arteries. 3. The time the condition has existed. 4. The rapidity of its 
growth. 5. The ability of the patient to carry out the requisite treatment. 

Diagnosis from — 1. Aphonia arising from other causes ; and 2. CEso- 
phageal stricture. The conditition of the aorta must be carefully studied. 
3. In Aortic valvular disease the murmur may be the same, and there 
may be concurrent hypertrophy. We must consider the line of transmis- 
sion, the point of greatest intensity of the murmur, and dullness in unequal 
spots. 4. From other forms of Tumors, by the pulsation, the murmur's 
location, and the course of the case, and by the presence of causes of 
aneurism. Other tumors may pulsate and have a murmur, but this is not 
transmitted. Put the patient in the "Knee and Elbow position," and the 
mass, if it is not aneurismal, will not pulsate. There will also be a loss of 
dullness in the back while the patient is in this position. 

Treatment. 1. Abdominal Aneurisms are within the reach of 
Surgical aid. If the tumor is near the bifurcation of the Abdominal Aorta, 
the application of a tourniquet will slow the current and hasten coagulation. 
Internal treatment in these cases is of little or no use. Ligation of the Ab- 
dominal Aorta has met with no success in twenty cases. 2. Thoracic 
Aneurisms. If the Aneurism is in contact with the chest walls and has re- 
sisted treatment, we may use Electrolysis, one needle being placed in the 



9 o 

sack, and from twelve to twenty-four contacts made. Absolutely immovable 
rest must be enjoined at the same time, for weeks and months, and with this, 
starvation of the patient within the limits of safety. If there is a history of 
syphilis, Potassium Iodide should be pushed to its fullest extent. Cardiac 
Sedatives, Aconite, Veratrum Viride, Hydrocyanic Acid, Bromides and 
Digitalis, when the accompanying heart trouble demands it, should be used. 

Exophthalmic Goitre. We have a neurosis of the ganglia controlling 
the action of the heart and the great blood-vessels arising from it, particu- 
larly the thyroid axis and its branches. 

Causes. All depressing influences, Prolonged anxiety, Debauches, 
Sudden shocks, Too frequent Pregnancies, Exhausting Hemorrhages, 
Chronic Diarrhoea, Exhausting Uterine disease, Irritation of the Sexual 
organs. 

Symptoms. We have a palpitation of the heart, which is difficult 
to control. Goitre and protrusion of the eyes, either of which may 
precede the other, but after a time both exist together. The Thyroid 
Enlargement is often enormous. It varies in size, rapidly increasing and 
again decreasing. It presents a feeling of elasticity, but not fluctuation. 
The thyroid arteries are tortuous, enlarged, and throb violently, the 
superficial veins being very prominent. The tumor is the seat of pulsation 
and thrill, and a strong arterial murmur is heard, more prolonged than 
that heard over the other vessels. The function of the larynx and pharynx 
may be interfered with, but the dyspnoea is due rather to the irritation of 
their muscles than to actual pressure. Protrusion of the eyeball is due to a 
want of perfect harmony in the ascent and descent of the lid and ball. The 
Cornea is dull, dry, and may be ulcerated. Tne globe of the eye appears 
sometimes to be very hard. 

General Symptoms. Patients are highly neurotic and emotional, 
and there are marked changes in temperament. Indeed, they may 
often seem to be deranged. They are pale, weak, and anaemic, and are 
easily fatigued. The appetite is sometimes poor, and may very often be 
greatly perverted. The digestion is weak and the stools ill formed, consist 
of undigested food, and are too frequent. 

The Course of the case is prolonged, often lasting many years. 

Termination : If no effect is obtained from the use of medicine, dilata- 
tion of the heart occurs with congestion of the lungs, dropsy, and death. 
The symptoms may all disappear under proper treatment, but are liable to 
return. Undue rapidity of the pulse may remain, together with a slight 
enlargement of the gland. 

Prognosis is generally favorable, except in very long standing cases and 
where we cannot remove the cause. 

Diagnosis. In Uncomplicated Goitres the heart's action is different. 
The gland does not pulsate, nor does it vary in size, and there is neither 
thrill nor murmur. 

Treatment is largely dietetic and hygienic. The cause must be dis- 
covered, and, if possible, removed. Special attention must be given to the 
dwelling, occupation, and diet. Sometimes an absolute milk diet is best, at 
others, a carefully regulated and restricted diet of cereals and milk. The 
nasal and other catarrhs must be treated. Argentic nitrate is very useful in 
these gastro-intestinal catarrhs. At other times the treatment must be 
directed to the ovaries. Among drugs Digitalis is very useful to control the 
heart. Caffein is used where there is a marked emotional condition. Iron 
should be used in all cases and extensively. It must be given in acceptable 



93 

forms, e. g., Tincture of the Chloride, Dialyzed Iron, or Iron by Hydrogen. 
Iodoform may be given with digitalis or with Iron. 
R Iodoform, 

Iron bv Hvdrogen, aa gr. i, 
M. ft. Pil. No. i. 
Ergot is useful when the condition of the stomach does not contra-indicate 
it. It is not wise to use more than two remedies at one time. 

Plethora is an undue increase in the total quantity of the blood or of its 
solid ingredients, so that it is either Qualitative or Quantitative. 

Causes are an excessive ingestion of highly nourishing food, combined 
with a lack of exercise, or it may be brought about by the sudden arrest of 
habitual discharges, e. g., of the Menses, Bleeding Piles, etc. 

Symptoms. The patient has a tendency to fullness in the head 
which is increased by sitting in a close room, stooping, etc. The color is 
heightened, with a tendency to become bluish. The action of the heart 
is heavy and labored. The Impulse is strong, and its Sounds long and 
heavy. There is a throbbing and distension of the vessels. The breathing 
is labored, and dyspnoea is easily excited. There is a tendency to conges- 
tion of the liver and lithaemia. Hemorrhoids are apt to form. The 
urine is of too high color and specific gravity. There is a general increase 
in the adipose tissue of the body. 

Prognosis. This condition disposes to Hemorrhage, Apoplexy, Pul- 
monary Complaints, and Hemorrhoids. 

Treatment requires a careful attention to diet and regimen. Scales for 
determining the weight of the body should be frequently resorted to, to 
ascertain what articles of diet bring about the desired effect. Drugs, such 
as salines and mineral waters are required to regulate the secretions and for 
meeting the indications as they arise. 

Anaemias are conditions of the blood in which its normal composition 
and quantity suffer. There are several varieties: i. Simple. 2. Toxic. 
3. Those which are associated with organic disease. 4. Idiopathic. Under 
the last we consider — (a) Progressive, (b) Pseudoleucsemia. (c) Leucaemia. 

I. In Simple Anaemia we have a deficiency in the amount of blood and a 
diminution in the number of red blood corpuscles, or the red blood corpus- 
cles alone may be diminished. Normally, a cubic millimetre contains five 
millions of blood corpuscles, the proportion of white to red, being one to 
four hundred. 

Causes of Anaemia are — 1. Want of proper food and sleep, the latter 
being just as important as trie diet. The regeneration of red blood corpus- 
cles is much more active during sleep. 2. Excessive discharges, e. g., 
hemorrhage from the Nose, the Uterus, or from Piles. 3. It frequently fol- 
lows fevers, inflammations, etc. 4. Anxiety or over-work, and depressing 
excitement. 5. Impure atmosphere and general mal-hygiene. 

Symptoms. The skin and mucous membranes are bloodless. The eyes 
and the nails assume a white pearly appearance. The heart becomes weak 
and irritable, and dyspnoea is easily excited by exertion. The sleep is light, 
disturbed and easily broken. The brain soon becomes tired, and the 
patient loses the power of concentration. The digestive system is weak, and 
dyspeptic distress is common after eating. The urine is pale and of low 
specific gravity, unless the liver or stomach are at the same time out of order, 
when it may contain urates and lithates. Anaemic patients are very prone to 
have neuralgia. It is among them that we find the most typical cases of 
neurasthenia and hysteria. The temperament very frequently undergoes 
changes, the patient becoming petulant, irritable and nervous. 



94 

Physical Examination reveals a soft blowing systolic murmur over the 
heart, and low continuous musical sounds over the great vessels. 

The Prognosis is always favorable when we can remove the cause. 

The Treatment consists in the removal of the cause, whether moral or 
dietetic, and the improvement of the patient's hygiene and surroundings, 
plenty of sunshine and fresh air being absolutely necessary. This may be all 
that is needed. Usually, we must at the same time restore digestion by the 
use of Bitter Tonics, Pepsin or Pancreatin, Malt and Mineral acids. It may 
be necessary to cure the gastro-intestinal inflammation before striking at the 
original disease. Iron, Arsenic and Cod-liver oil are all invaluable. 

II. Toxic Anaemia may be either Malarial or Metallic. 

i. Malarial may occur in those who have had malarial fever, or it may- 
appear at first as an anaemia without there having been apparently any 
previous malaria. 

Symptoms. We have a destruction of the red blood corpuscles by the 
poison. The spleen is enlarged, assuming the form known as "Ague Cake." 
The liver is apt to suffer, and a granular black pigment is found in the blood. 
There is a greater tendency in this form to neuralgia. At various times 
patients exhibit other signs of malarial poisoning. 

Diagnosis is made by its occurrence in malarial districts and by our 
inability to obtain a history of any other cause. 

Treatment consists in the persistent use of arsenic and quinine, which, 
in combination with iron, have a peculiarly marked effect. 

2. Metallic. Under this head we consider poisoning by copper and 
lead, that by lead being most common. 

We base our Diagnosis on — i. History of the occupation, habits, etc., 
of the patient. 2. The previous occurrence of colic. 3. The presence of a 
"blue line" on the gums; and 4. The reaction of the skin, when moistened 
with sweat, to the hydro-sulphuret of Ammonium, black spots of sulphuret 
of lead being deposited. 

III. Anaemias Associated with Organic Disease. In incipient 
Cancer of the stomach, incipient Cirrhosis of the liver, Bright's disease, and 
Intestinal cancers, we may have anaemia long before the appearance of the 
usual symptoms. 

IV. Idiopathic Anaemia is associated with changes in the blood-making 
organs, viz., the spleen, lymph glands, and lymphoid tissue wherever found 
throughout the body. We have an abnormal increase in the colorless blood 
corpuscles, which is known as leucaemia, or a decrease in both, pernicious 
anaemia. In Leucaemia the blood may look normal, but is more frequently 
like thin pus, coagulates poorly, and its clots are soft. The red blood cor- 
puscles are pale and poorly developed, and are deficient in number. The 
colorless blood corpuscles are large and have several nuclei, and their pro- 
portion to the red may be increased to one to ten or one to six. Perverted 
globulins may also be found in the blood. The Spleen is firm, heavy, and 
enlarged. It may be six or more pounds in weight. The pulp is dark and 
studded with grayish bodies, which are enlarged Malpighian corpuscles. 
These may run together, forming blocks one-half to one inch in diameter. 
Lymphoid Tissue elsewhere enlarges. The glands are painless and movable, 
and the skin over them is not reddened. The lungs, liver, etc., all contain 
spots of this hypertrophied lymph tissue. The marrow of the long bones, 
which seems to have the power of elaborating red blood corpuscles, has its 
normal structure changed in this anaemia. Hence we have the three forms, 
Splenic, Lymphatic, and Medullary. 



97 

Symptoms. We have an apparently causeless, extreme, progressive 
anaemia, the patient often having a waxy appearance. At first loss of 
flesh may not be marked. Shortness of breath and palpitation of 
the heart follow exertion. The mucous membranes are pale, and the 
sclerotic white. Hemorrhages from the nose, gums, or bowels, or 
into the retina, are common ; this latter causing a dimness of vision. Some- 
times excessive sweating and fever are common. On long standing, 
oedema of the feet and legs comes on. The lymph glands are enlarged, 
and give rise to Lymphadenoma, or Hodgkin's disease. If it is of the sple?iic 
type, the spleen is enlarged. If lymphatic, pain is felt in the seat of the 
glands, either superficially or deeply placed. Those in the abdomen may 
be so large as to press upon the aorta and simulate aneurism. 

Prognosis. It is always a fatal disease, lasting from six months to six 
years. 

Treatment is merely palliative. The patient goes on from bad to worse, 
and death occurs from Syncope, Diarrhoea, Asthenia, Hemorrhage, or some 
intercurrent attack, the most common cause being Epistaxis. 

Pseudo-leucaemia begins in the same way as the above, with a progressive 
failure in health, with a tendency to hemorrhages. The spleen and the gland 
may or may not be enlarged. If there is no enlargement of the glands, the 
marrow undergoes changes. At first there is no increase in the colorless blood 
corpuscles, but towards the last this Pseudo-leucaemia may change to Leucae- 
mia, at which time we do find an increase in the colorless blood corpuscles. 
In Leucaemia the blood-making glands are irritated and a great abundance 
of colorless blood corpuscles, which do not develop fully, is produced ; and, 
as the red are destroyed, anaemia results, because the unformed colorless 
blood corpuscles cannot circulate to advantage. 

The Prognosis in a fully-developed case, seems to be fatal. The dura- 
tion may be from a few months to two or three years. In the progressive 
form life ends in a few months. 

Diagnosis. We recognize an intense anaemia without any apparent 
cause, and, as far as we know, no organic disease of any viscus. If there 
is no enlargement of liver, spleen, or lymph glands, we should turn our 
attention to the rarer form of Medullary. 

Treatment is merely palliative and symptomatic. The indications are 
to regulate the diet and relieve pain. Iron, Arsenic, and nutrients act only 
in a general way, and should not be regarded as specific. Transfusion of 
blood should be condemned. 

Chlorosis is an affection most frequently seen in young girls, but may 
occur in males also. It is associated often with derangements of the sexual 
apparatus, especially with menstruation. Hysteria and perverted temperaments 
are very often associated with it. The face assumes a pale, yellowish, green 
tinge, almost like a faint trace of jaundice, but is distinguished from it by 
the appearance of the conjunctiva, which is pearly white. The red blood 
corpuscles are reduced in number, but the colorless blood corpuscles are not 
increased. There is some pigmentary alteration in the blood, but it has, so 
far, eluded chemical test. 

Symptoms. At first there may be no loss of flesh. The extremities 
are cold, and there is a feeling of great fatigue, with a tendency to palpita- 
tion on the slightest exertion. The digestion is more markedly disturbed 
than in ordinary anaemia. The appetite is lost or may be perverted. There 
is a great tendency to neuralgia. Sleep is disordered, and the patient grad- 
ually becomes morbid in temperament. We have here associated a disorder 
of the mind, digestion, and the menstrual function. 



93 

The Prognosis is very good, but cases are often obstinate on account of 
the difficulty of removing the cause. 

Treatment consists in attention to diet and hygiene. The exercise of 
moral influences, such as change of scene, occupation, etc., and the removal 
of local disorders, such as ovarian, uterine, and prostatic irritation arising 
from masturbation ; and the administration of remedies to restore the 
condition of the blood. Iron is indicated, but its administration is attended 
with difficulty owing to the great digestive disturbance. We should endeavor 
to effect a judicious concealment of the Iron, and persist in its use until we 
are perfectly assured that it does harm. It may be given with dilute phos- 
phoric acid or in pill-form. 

R Iron by Hydrogen, and Phosphorus in minute doses. 

Strychnia and mineral acids should also be given. All sedatives must be 
avoided. 

IV. DISEASES OF THE SPLEEN. 

The Spleen is subject to — i. Rupture. 2. Enlargement from Malaria or 
Chronic congestion. 3. Inflammation of Capsule, or Substance with the 
formation of abscess. 4. Degeneration. 5. Cancer. 6. Hydalid Cysts. 
7. Leucaemia. 

1. Rupture is usually the result of traumatism, but may be spontaneous 
in the swollen spleens of Relapsing and Typhoid fevers. 

2. Enlargement, very common in Typhoid fever, of which it is a 
characteristic symptom, and also in Relapsing and Typhus fever and Malaria. 
It is particularly common in chronic Malaria, in which it attains the large 
form known as " Spleen Cake," or Spleen tumor. It is also common in 
heart disease. It is recognized by — (a) Percussion and Palpation, (b) By 
a history of Malaria; or (c) A dull pain in that locality may call our 
attention to it. 

3. Inflammation may be limited — (a) To the Capsule, when it becomes 
a local Peritonitis, which is very common in this situation in relapsing fever, 
less so in Typhoid. Syphilitic and Tuberculous Peritonitis are very apt to 
be located here. 

The Symptoms are: — Pain and tenderness, and evidences of enlarge- 
ment. They are, of course, merged in those of the disease* causing it, where 
there is a history of the fever or of Syphilis. 

The Treatment would be the same as for any other local peritonitis. 

(b) Primary inflammation of the Substance of the Spleen is rare. 
Secondary is more common as the result of Pyaemia, or the lodgment of 
Emboli, causing an infarct which goes on to organization or suppuration. 
4. Degenerations. Amyloid is the most, common. The spleen becomes 
very large, and it is associated with amyloid degeneration of the kidney or 
of the liver. 

The Symptoms of the degeneration are referred more to the degenera- 
tion of the liver or kidney. We should suspect it where there were causes 
for the disease, or from the disease appearing in the kidney as shown by 
copious urine and presence of epithelial cells, giving the mahogany-red 
reaction. 

Prognosis is fatal. 

Treatment is merely palliative and symptomatic. 

Cancer of the Spleen is rarely primary, and is accompanied by a can- 
cerous cachexia. The organ is nodular and not uniformly enlarged, and is 
the seat of great pain and tenderness. 



IOI 

In Our Diagnosis we should eliminate Amyloid Degeneration and 
Leucaemia. 

Hydatids of the Spleen. The morbid Anatomy is the same here as 
elsewhere. There may be a single or multiple cysts which may be situated 
in, or only attached to, the organ. The spleen has a peculiar parchment-like 
feel on Palpation, giving a distinct sense of fluctuation. It contains a pel- 
lucid liquid of a low specific gravity, with no albumen. The tumor is 
painless and grows slowly, the health being but slightly affected. 

Diagnosis. There are scarcely any other kinds of cysts to which this 
organ is subject. We base our diagnosis on the absence of signs of other 
splenic diseases. 

Prognosis, if it is recognized, is good. If left alone there is danger of its 
rupturing or a pyaemia being set up. 

Treatment is purely Surgical, and consists in the evacuation of the cyst. 
A single puncture may suffice, but if it refills it must be again punctured 
and injected. If it obstinately recurs, a fistula must be established and the 
cyst injected and drained until it finally closes, or laparotomy may be per- 
formed and the tumor enucleated. 



V. AFFECTIONS OF THE RESPIRATORY 

TRACT. 

I. THE NOSE. 

The Nasal Cavities are subject to Catarrh, which may be either Acute 
or Chronic. The word Catarrh is applied to all inflammations of mucous 
membranes. 

Acute Nasal Catarrh is not of very great importance; but owing to its 
great prevalence, its study possesses considerable interest. 

Its Causes are those which generally produce " a cold in the head," e.g., 
atmospheric changes, damp and cold feet, exposure to draughts of 
air or irritating vapors. The tendency to " take cold " (as it is called) 
is associated with a lowered tone of the system, and also with an individual 
weakness of the Mucous Membrane. Thus, Scrofulous subjects are 
peculiarly liable to it. It may also be brought about by a defective shape 
of the Nostrils. 

Symptoms are both Local and General. The Local Symptoms are 
— i. Smarting pain in the nasal cavities. There is a stage of Watery 
Secretion. This becomes gradually thicker, and finally muco-purulent. 
The General Symptoms consist in a feeling of Languor and Dullness, 
aching across the brow, a "creepy" sensation throughout the system, and 
pain in the limbs. The voice changes, and is apt to be lost. The 
Temperature may run up to ioo^° F., or in a sensitive child to ioi° F. 

Prognosis. With little children only is the disease serious, in so far as 
it may offer an obstruction to breathing. 

The Diagnosis is very plain. When we meet with Coryza, we should 
be on the lookout for Measles. 

Treatment. The patient should, if possible, stay indoors and take rest. 
We may order a Dover's powder and a warm foot-bath. A cap or handker- 
chief should be worn on the head at night, or we may adopt a Tonic Treat- 
ment, giving viii-xii grs. of Quinine, and paying attention to the clothing, 



102 

etc. A snuff of Sub-Nitrate of Bismuth is often of service. A person 
tending to " take cold in the head " should be subjected to Systemic Treat- 
ment, special care being taken of the skin. Nutrients, as Cod-liver Oil, and 
regular Gymnastics should be recommended. 

When a cold in the head runs on for some time we have what is known as 
Chronic Nasal Catarrh. This either arises — i. From repeated attacks 
of the Acute; or, 2. May begin as such from the outset. This is especially 
the case in persons of relaxed tone and in Syphilitic and Scrofulous subjects. 
3. Injuries of the nose may produce it. This Affection may be in the Nasal 
Cavities or in the upper part of the pharynx. The mucous membrane is 
thickened and hypertrophied. 

Symptoms. The discharges from the nasal cavity in chronic catarrh 
vary in quantity, consistence and color. They may fall backwards into the 
throat and cause hawking. This is unfavorable, as it induces congestion of 
the mucous membrane there too. The voice is altered, owing to suppres- 
sion of the nasal sound. A habit of mouth breathing is developed, owing to 
the accumulation of mucus in the nasal cavities. A chronic Pharyngitis 
may be brought about. The General health, too, suffers indirectly. 

The Diagnosis of Chronic Nasal Catarrh presents no difficulty, but its 
exact location by means of the Laryngoscope requires practice. It is only 
recently that this has come into vogue, and the Prognosis is thus rendered 
more favorable than before. 

Treatment. Hygienic Treatment is essential. We must pay attention 
to the habits, dress and tone of the patient. All taint of Syphilis or Scrofula, 
when they exist, should be eradicated. Locally we may use Solutions of Sul- 
phate of Zinc and Nitrate of Silver, or an astringent powder may be blown 
into the parts. The condition of the mucous membrane may be such as to 
demand the application of the Cautery. A bone may have to be sawn away, 
as from Exostosis, or there may be a displaced Septum, requiring special 
treatment. We should, however, always try mild local measures first. 

II. THE LARYNX. 

Laryngitis and Croup. Laryngitis may be 

1. Catarrhal. 

2. (Edematous. 

3. Ulcerative. 

Of the Catarrhal form we have — 1. A Mild; and 2. A Severe type. 

I. Ordinary Catarrhal Laryngitis affects all ages. 

Causes are Atmospheric Changes. The Larynx when heated is suddenlv 
cooled. Teachers, Public Speakers, Preachers, and all persons who use their 
voices much, persons of relaxed fibre, are prone. 

Symptoms. There is — 1. Pain in the Larynx of a smarting or burning 
character, which is increased by coughing or laughing. 2. Cough, which 
is hard and dry, and causes pain. 3. The Voice is altered, becoming 
hoarse, rough and weak. 4. There is General Malaise and slight Febrile 
symptoms. 5. The Laryngoscope shows Redness and Slight Swelling. 
In two or three days the Secretion of Glairy Mucus begins, thin at 
first, becoming thicker, and gradually diminishing in quantity, the attack 
lasting from five to ten days. In nervous children with acute Catarrhal 
Laryngitis there is more or less Muscular Spasm and Symptoms of Croup. 
But grown persons as well may have Symptoms of Croup. When we speak 
of Croup Symptoms, a coarse, hard, brassy, ringing Cough is meant, e. g., a 
Croupy Cough is noticeable is Bronchitis. 



105 

Diagnosis is easy, and the Prognosis is favorable, but attended with 
some anxiety, as in children ordinary Cartarrhal Laryngitis may run into 
something else 

The Treatment is simple. The voice must not be used. The air of the 
patient's room must be kept warm and moist. Counter-irritation over the 
front of the neck by means of Iodine. We may use Fomentations, or simply 
cold water, protected with Rubber or Oil Silk. Local applications of water, 
Lime Water, Weak Ammonia, or Lime Water with a little Carbolic Acid, 
are useful. Internally we give some Sedative and Laxative as the following : 
R Morph. Acetat. grss., 

Syrup Ipecac f3iij, 
Sol. Acetat. Amnion, f^iv. 
Mft. Sign. : Two Teaspoonfuls every four hours. 

We may use besides Spirits of Mendererus, and about 8 grains of Quinine 
along with the above. Children bear large doses of Quinia bv the Rectum 
well. 

Severe Acute Laryngitis is dangerous to the child ; much more so 
than to the adult. 

Its Causes are the same as those of ordinary Laryngitis, but usually there 
are predisposing causes, as former attacks. 

Symptoms. Fever of unusual severity. The Temperature running up 
to io2° F. to 103 F. The Skin is hot and moist. The Pulse is rapid, 
strong and excited, the breathing hurried. There is severe pain in the 
Larynx. The Voice is reduced in volume to a mere whisper sometimes. 
Cough is frequent and painful, and is reduced in force to a wheezy sound. 
The child is restless. There is a sense of oppression and obstruction. 
Sometimes the child sits erect in order to breathe. Examination of the 
Fauces and Larynx shows no pseudo-membrane, but there is intense 
congestion of the Mucous Membrane. This reaches its height in two days. 

The Duration of the Disease is generally from seven to nine days, but it 
may last fourteen. 

The Diagnosis is easy as to the presence of Laryngitis, but in a child we 
are always anxious about the existence of a pseudo-membranous deposit. 
Indeed, we can often only determine its absence by the fact of its not being 
discharged, and the child getting well. 

The Prognosis is favorable, but anxious. 

Treatment. Put the child to bed. Keep the temperature of the sick 
'room humid and even. Apply counter irritation to the affected region. If 
the symptoms are very severe, a few leeches may be applied to the throat, 
followed by a fomentation. Blisters are not recommended. Cold packs 
kept on night and day are preferable. Frequently steam the throat by the 
atomizer from a funnel over some hot sedative liquid. Internally, give 
Calomel with Dover's powders in pill form to suit the case, e.g., y^ gr. 
Calomel with 2 or 3 grains of Dover's powders for three or four days. Also, 
give full amounts of Quinine at different times. When the symptoms sub- 
side, use alkaline solutions, as Ammonia, etc. 

Croup is the name applied to an acute febrile disease, attended by obstruc- 
tion of the Larynx with Spasms, causing a peculiar sound of the voice and a 
Cough. There is always present an element of inflammation and spasm. 
When the Spasm is the chief element we speak of it as Spasmodic Croup ; 
on the other hand, we may have Pseudo-Membranous Croup, in which the 
spasm is a minor element. 

Spasmodic or False Croup is a mild or Catarrhal Laryngitis with a 
high degree of spasm of the Muscles of the Larynx and an inflammation of a 
light degree. 



io6 

Causes, i. Childhood ; and 2. An individual predisposition which 
is very marked in some families. 3. It occurs mostly in children before the 
close of the first dentition. Indeed, it would seem as though there is a 
tendency in the first dentition to bring on this disease. 4. Digestive 
Disturbances. 5. Some adults have Croup, but such cases are rare, and 
generally occur in persons of a highly neurotic temperament. 

Symptoms begin with those of a slight cold. They point to irritation 
of the Throat and Larynx, but are often overlooked, and the onset of Croup 
is sudden, frequently awakening the child after midnight. The child is 
alarmed and agitated. The skin is covered with sweat. The child is 
febrile. Its expression anxious and face flushed. Breathing is difficult, 
and at each inspiration there is a loud stridulous croupy sound. The supra- 
sternal notch sinks. The chest recedes. The cough is hoarse, weak, and 
croupy. Speaking is impossible, and the voice is reduced to a whisper. 
The Spasm is relaxed by the very thing it brings about, viz., the accumula- 
tion of Carbon Dioxide in the system, and soon the attack is over. They 
generally last a few moments. Rarely does the child have a second attack 
that night. Next day the child is feverish and croupy, and there is danger 
of a recurrence of attack the next night. The Laryngoscope shows no 
congestion. 

The Diagnosis is easy, if we bear in mind the Suddenness of the Attack, 
the Constitutional Disturbances, and the way in which it yields to treatment. 

The Prognosis is altogether good. 

The Treatment is simple. The principal point is to guard against 
future attacks. We should instruct the parents as to the care of the child 
when it has a cold. Such children are very sensitive. When they have a 
cold they should be kept in bed, in a warm room, and on light diet. Some- 
times a sponge dipped in hot water and applied to the Larynx does good. 
A hot bath will often break up a Spasm. Sprup of Ipecac causes vomiting 
and relaxes the spasm. Mouth-breathing is apt to bring on an attack. 
During sleep the throat gets dry, and this throws the child into a spasm. 
Hence, a child subject to croup should be waked up at intervals of a few 
hours during the night, and a teaspoonful of gum-water, or something 
similar, administered to keep the throat moist. 

Membranous or True Croup bears a close resemblance to Diphtheria as 
regards its Pathology. We may have Membranous Croup either Idiopathic 
or associated with Diphtheria. It is hard to say what is the relative frequency ( 
of True Membranous Croup and Diphtheritic Croup. In a large number of 
cases it is not Idiopathic. Membranous Croup develops gradually, and is 
called " Creeping Croup." 

Symptoms begin with Fever, Languor, Lassitude, Sore Throat, Cough, 
Hoarseness, and alteration of the voice. These last for two, three, or four 
days, but may be so slight that they are overlooked, and Membranous 
Laryngitis appears suddenly. Then come Obstructive Symptoms. The 
Breathing grows more and more difficult. The voice becomes more and 
more whispering. The hoarse character of the cough is suppressed. It 
becomes a mere effort at coughing. The Chest cannot be distended, the 
Lungs cannot be filled, and the base of the Chest is pressed in at each 
inspiration. The Supra-sternal Notch is sucked in from the same cause. 
These symptoms are attended with a weakening of the Pulse, Livid lips and 
Features. There is interference with Oxidation, and spasms of Dyspnoea, 
which threaten and sometimes cause sudden Death. The child is Restless 
and tears at its Throat. We have an accumulation of Carbonic Acid, and 
Death comes from Apnoea. In some cases there has been Membrane 



1 09 

in the Fauces before the Laryngeal symptoms. There may be no Membrane 
in the throat. The Tonsils are red and the Pharynx injected. The 
Glands at the angle of the jaw may be tender and swollen, but when the 
Membrane is in the Larynx first we have very little lymphatic enlarge- 
ment, whether it be Diphtheritic or Idiopathic. When Diphtheritic we 
have more adynamic symptoms. But we cannot base our Diagnosis on 
Constitutional Symptoms. They both run into extreme Debility. Obstruc- 
tion may become complete and death take place on the third day, but more 
commonly the case lasts from six to nine days. 

Morbid Anatomy. We find a deposit in the Larynx, beginning at the 
vocal cords. We have a cast of the Larynx, or it may be broken at points. 
This membrane is whiter and tougher than it is in the Pharynx. It may 
reach down to the Bronchi. The mucous membrane beneath is raw, con- 
gested, and excoriated, but is not ulcerated. The Post-Tracheal and Bron- 
chial Glands are enlarged. The Lungs have Patches of Catarrhal Secondary 
Pneumonia. 

Diagnosis of Membranous Croup is easy. Simple Catarrhal Laryn- 
gitis may have severe symptoms. Where Spasmodic Croup occurs there is 
no difficulty. Its sudden onset, and the fact of its yielding suddenly to 
treatment, would at once reveal simple Laryngitis. The Diagnosis is greatly 
assisted by a patch of membrane on the tonsils. The child may vomit a 
portion of membrane, and this reveals the true nature of the case, whether it 
be of the Idiopathic or Diphtheritic type. 

Prognosis is very grave. Many cases die. 

Treatment. Use prompt, strict treatment in apparent trivial diseases. 
Anticipate serious developments by Restraint in Bed and Attention to 
Hygiene. Regulate the Diet. Keep off Draughts. During the first day or 
two use Muriate of Ammonia and Ipecac with Squill and Opium, but as soon 
as local trouble appears give a steady course of Calomel. We may associate 
Chlorate of Potassium with Muriate of Ammonia, on account of liability to 
Faucial Irritation. For this- early stage use something like the following : 
R Ammon. Muriat., 

Potass. Chlorat. aa Z\, 

Mist. Glycyrhiz. Comp. f 3 i i i . 

M. ft. S. : f£i every three or four hours. 

For very young children substitute Syrup of Ipecac for Potash. If this 
has no effect give gr. iii of Calomel, to purge, and after this gr. x /> every 
one, two or three hours. It is well to give the Calomel with an alkali, as 
Carbonate of Potash. It never salivates. If it is a case of Putrid Laryngitis 
in Scarlet Fever, this treatment would be futile. Meanwhile give Quinia by 
the Rectum, and apply Iodine over the neck. Protect the surface by light 
batting of cotton. Give inhalations of Lime Water or Boracic Acid, or 
Pepsin and Lactic Acid. Put a couple of grains of Pepsin and a few drops 
of Lactic Acid into the cup of the Atomizer. Nourishment must be kept 
up. Heart failure is a great danger. Give Alcohol ; it is well borne. But 
the Symptoms of Obstruction may go on. There is danger of sudden death 
from Heart Clot, or Pulmonary Collapse. Perform Tracheotomy where the 
symptoms persist. It is a hard operation in a child, but there can be no 
apology for not performing it. The Fatal results are due to delay. The 
Temperature of the room must be high and the Air moist. The surface of 
the tube must be covered with Glycerine, and the tube cleaned from time 
to time. 

Chronic Conditions of the Larynx. Under this head we have two 
conditions. Chronic Laryngitis may be simply Catarrhal or Ulcerative, 
under which head we have — 1. Tuberculous. 2. Syphilitic. 3. Cancerous. 



no 

Chronic Laryngitis follows repeated Attacks of Acute Laryngitis. It 
is most common in those who have abused their voice. It may come on 
from the start as Chronic. We have Redness of the Vocal Cords, 
Epiglottis and Lining of the Larynx; Enlargement of the Follicles, 
Accumulations of Morbid Secretions; but the muscular movements of 
the Larynx are well preserved. 

Symptoms are Local. There is Smarting and Fullness in the 
Larynx. The Epiglottis, if swollen, may cause a disposition to swallow. 
There is Cough of a hard, Laryngeal character. The voice is hard, harsh 
and hoarse in tone. Mucus expectoration is great. The general health 
may be well preserved. 

Diagnosis. We recognize the disease by the Laryngoscope. We see an 
absence of any Bronchial or Pulmonary Disease. The Maintenance of the 
General Health is an important thing in the Diagnosis. Where it is 
Syphilitic or Tuberculous we have impairment of health. 

Prognosis is good if the patient breaks up the Habit of Life inducing 
the Disease. 

Treatment. The patient should learn how to use his voice rightly; not 
abuse it. Local Treatment can be employed by puffing Powders into the 
Larynx, guided by the Laryngoscope. Internal Remedies are Alkaline Salts, 
as those of Potash and Soda, and Copaiba. 

R Ammonii Muriat., or Brom., gr. c, 
Ext. Eriodyc. f^i, 
Mist. Glyc. Comp. f^iii, 
M. ft. S. : fgii ter. die. 

If there is soreness we add Bromide of Ammonia. Exte?-nal Counter-Irri- 
tation is useful here. 

I. In Tuberculous Laryngitis we find a remarkable degree of Swelling 
over the Arytenoid Cartilages. This is so often met with that it has a 
Diagnostic value. The Cartilages are rounded. In Ulcerative Laryn- 
gitis we may or may not find Tubercles. They may be at the base of the 
Lungs. The Lungs may be involved first, or the Larynx may. Tuberculous 
Laryngitis may be Primary or Secondary to Tuberculosis elsewhere. 

Symptoms are Troublesome Cough, Expectoration of Glairy Mucus 
and some Pus, and severe Pain in the Larynx. Before long there is 
Difficulty in Swallowing, owing to the Inflammation of the Arytenoids. 
Death may be hastened by taking food. The Voice is altered, being 
reduced to a whisper. There may be complete Aphonia. The General 
Health may fail. Some cases last only a few months; others several years. 

Diagnosis. Extreme care is necessary. It is important to know whether 
the Lungs are involved or not. This is often difficult. Rales are formed, 
and there is a complication of sounds. The Chest must be ausculted, both 
when the mouth is open and closed. The determination of the existence of 
the disease in the Lungs has an important bearing on the Laryngeal trouble. 
If the Lungs are healthy, and there is no Syphilis, yet at the same time 
obstinate Laryngitis, we are led to regard it as a Catarrhal Laryngitis. 

Prognosis is bad but the case may undergo temporary Improvement. 

The Treatment should be directed to the Improvement of the General 
Health, to the Pulmonary Trouble, and to the administration of Local 
Remedies, for the Laryngeal Trouble by the use of Inhalations. The appli- 
cation of Iodoform in solution, paste or powder. The Alkalies and Nitrate 
of Silver are not so safe. Food should be taken by a tube. If Dyspnoea or 
Dysphagia threatens life, tracheotomy may be indicated. 

II. Syphilitic Ulceration of the Larynx is a constitutional expression 
of syphilis. The Anatomical Characters differ from Tuberculous. Here the 



H3 

Perichondrium is swollen, the Cartilages break down, and the Ulcers are 
superficial and deep. They are irregular and extensive, — all parts of the 
Larynx being affected. Not rarely ulceration of the Fauces is associated. 

Prognosis is favorable as regards life, but if not recognized early, 
Deformity is left behind, Cicatrices form, and fibrous bands encroach on the 
aperture. The Voice is often prematurely affected, and also Deglutition. 
This Stenosis causes obstruction. 

Treatment. Internal Constitutional Medication works wonderful 
results. External Counter irritation should be made over the Cartilaginous 
portion of the Larynx with the Laryngoscope. Nitric Acid, Caustic, or Sul- 
phate-of Copper may be applied locally to the ulcers. Sometimes Trache- 
otomy is necessary in Stenosis. 

Tumors of the Larynx may be — i. Simple. 2. Malignant. Mostly they 
are Papillomata. They may occur at any age or may be congenital. They 
are met with late in life. In shape they are sesile or pediculated. Their 
rate of growth differs. 

Causes are obscure. They seem to occur in persons who are predisposed 
to such growths. 

Symptoms are apt to be overlooked. There are alterations in the voice, 
it grows weaker, is unreliable, loses volume, cracks or breaks, is sometimes 
whistling — the tumor being between the Vocal Cords. There is Pro- 
gressive Dyspncea complicated with spasms from time to time. This 
Dyspnoea in a typical case is permanent. Pain and Cough are not very com- 
mon. The Cough, when it exists, is hard and spasmodic. The General 
Health does not appear to suffer. 

Diagnosis must be made with the Laryngoscope. This will reveal 
whether there is one Tumor or many. The absence of Syphilitic History 
and Tuberculosis must be taken into consideration. 

Prognosis of simple tumor is good. But if treatment is postponed, 
Tracheotomy may have to be performed, owing to sudden spasm. 

Treatment consists in the removal of the Growth. If it cannot be 
reached through the mouth Tracheotomy must first be performed. 

Cancer of the Larynx. The History of Cancer is a painful one. Cancer 
appears in elderly Subjects. It may be Primary or Secondary to growths 
'in the Neighborhood. There is excessive Pain. Swallowing is difficult. 
There is more or less extinction of the Voice, Cough, and Expectora- 
tion. 

The Diagnosis by means of the Laryngoscope and the History is easy. 

Prognosis is hopeless. 

Treatment can only be Palliative, and consists in supporting the patient's 
system. 

Diseases of the Bronchi and Trachea. 

Bronchitis is — I. Acute. II. Chronic. Under Acute forms come — 
1. Simple. 2. Capillary. 3. Mechanical, with Hypostatic Congestion. 
4. Secondary. 5. Fibrinous. 

I. Simple Acute is an inflammation of the lining Membrane of the 
Bronchial tubes. It is excessively frequent. 

Causes. 1. Climate. The disease is more common at severe seasons 
of the year and in rough climates where there are sudden changes. In most 
climates it is not so bad unless Cold winds exist. High winds, much Dust, 
and a Dry climate favor Bronchitis. 2. A lax, atonic state of the sys- 
tem predisposes to it. 3. Age. It is most common in early life. 4. Ex- 
isting Cardiac Disease. 5. Occupations in which the person is 
exposed to irritating vapors or dust as in Mines. 6. It is an attendant on 



H4 

Certain General Diseases, as Measles, Typhoid Fever, and most Blood 
diseases. It frequently complicates Phthisis and Emphysema. 7. In rare 
cases it is connected with the Gouty and Rheumatic Diathesis. 

Morbid Anatomy. At first there is a state of dryness of the parts; 
then Injection, Swelling and Redness of the Bronchial tubes. The Swelling 
is very variable, and may amount to Obstruction. There are patches of 
inflamed areas, and the swelling completes the closure of the small tubes, 
after which there is a Morbid Secretion. This condition is called Capillary 
Bronchitis. Sometimes we have a Fibrinous Formation, which may fill up 
the tubes of one side. Usually this Fibrinous Formation is a true morbid 
Product of a Pseudo-Membranous character. In a child we may have little 
patches of collapsed Lung, from occlusion of the bronchial tree where the 
lesions are symmetrical and bilateral. 

Symptoms — General. There is a Rigor, followed by more or less 
Fever, attended with aching Pains in the back, limbs and head. Often the 
Febrile Symptoms are not marked. There is pain in the Chest and hard 
Cough, increased by talking or using the voice. Pain under the Sternum 
is often complained of. Otherwise the symptoms are very slight. After 
this condition has lasted for about two days the cough grows softer, and 
there is a free, soft, muco-purulent expectoration. The General Symp- 
toms subside in a few days, and the attack terminates in from seven to 
fourteen days. 

Physical Signs. We observe no change on Inspection or Percussion. 
Auscultation reveals sonorous and sibilant Rales behind and down to the 
root of the Lungs. Later on Mucous Rales are heard at the base of the 
Lungs. These mark the two stages of — 1. Dryness; and 2. Secretion. 

II. Capillary Bronchitis is more common in children. It may be 
Primary or Secondary. When it is Primary it is acute and severe. The 
Temperature may be 102 F. or 103 F. The Pulse rapid. The Face 
flushed. The Breathing very rapid. In a child the respirations may be 60, 
80, or even 100 per minute. In an adult 45 to 50. In children the base of 
the chest recedes. The respirations are shallow. There is Restlessness and 
Discomfort, which is not relieved, because there is no Expectoration. Later 
the Expectoration becomes soft and more muco-purulent, and then the 
Symptoms subside. 

Physical Signs. In general there is no impairment of Percussion Reso- 
nance. Auscultation gives very extensive Sub-crepitant Rales, most marked 
over the antero-posterior portion of the Lungs. With these may be mixed 
some Sonorous Rales. Respiratory Murmur is in many places weak. Over 
the upper portion of the Lung there may be Supplementary increase of 
Respiratory Murmur. After a few days Nervous Symptoms may appear. 
We have Jactation, Failure of Peripheral Circulation, Engorgement of the 
Lungs, and Death from Carbonic Acid Poisoning. It is often fatal in four 
or five days ; but it may last ten or twelve. Convalescence is apt to be pro- 
tracted. The whole Duration may be fifteen to twenty-one days. It is very 
different from the ordinary Bronchitis. 

Collapse is a term applied to Subjects who have fully expanded Lungs 
which have afterwards collapsed. It is more common in children as a com- 
plication — their respiratory muscles are weaker — but it may occur at any 
period of life, and especially when the System is exhausted. 

Explanation. A Bronchial Tube has been partly closed by the Swelling 
of the Mucous Membrane, and then by the thick Secretion. A thick plug is 
formed. The act of Expiration, when violent efforts are made, is more 
powerful than inspiration. Thus, from parts of the Lungs where the 



Obstruction is greatest, the air is pumped out and not replaced. A certain 
amount of air is absorbed, and we have a return to the Fcetal state. Either 
a spot may be affected the size of a cherry or a pin's head, or an entire 
lobe may be involved. The portions most liable to collapse are where the 
bronchitis is worst, and where it is difficult for the air to get back, e.g., the 
Intervertebral Gutters, and along the attenuated anterior margins of the 
Lung. It also may extend into the Mediastinum. 

Morbid Anatomy. The collapsed part of the Lung is sunken below the 
surrounding surface. It has a purplish color and is hard to the feel. It 
does not break down. If we inflate the Lung this collapsed portion will 
expand. This process of Collapse is inseparably connected with Bronchitis. 
It is rare as we have said, except in very attenuated systems. 

Symptoms. The occurrence of this Complication would be recognized 
by Dyspnoea. Frequency of Pulse and Respiration, without rise of Tem- 
perature as in Pneumonia, by the appearance of areas of impaired Dull- 
ness on percussion, and Distant Respiratory Murmur. There is not 
that intense Dullness of Consolidation of the Lung. 

Mechanical Bronchitis is simply Bronchitis in a person subject to 
Venous Stasis in heart disease. In these the Bronchitis is apt to be Subacute, 
but we may have spells. The chief point is there is a constantly marked ten- 
dency to Congestion and CEdema of the Lungs. We have a combination of 
pure Subcrepitant Rales with the ordinary Rale of Bronchitis. It may run 
into Subacute. A high degree of disturbance of breathing is caused with 
very little fever. Disorder of breathing and pulse is due to Cardiac disturb- 
ance. These are apt to be overlooked as the physician may only regard the 
Heart. 

Secondary Bronchitis ensues in other acute diseases, blood disorders, 
Measles, and the like. It may be secondary to Pulmonary Phthisis. Some 
of these forms are inevitable. We hardly pay attention to it if moderate, 
e.g., in Typhoid, Measles and Whooping Cough, the bronchitis is apt to 
be troublesome. It assumes more of the Capillary type especially in Whoop- 
ing Cough, Diphtheria, and Measles. The gravity of any disease is increased 
by Bronchitis. It may run into Catarrhal Pneumonia or be associated with 
extensive Hypostasis of the Lung or Collapse. 

Fibrinous Bronchitis is rare. It usually occurs in adults. There 
must be a predisposition. 

Symptoms. There will be Fever of an irregular character for an 
indefinite time. The Pulse is rapid. There is a disposition to Debility. 
The Cough is hard and troublesome. There is violent hawking, but little 
expectoration. 

Physical Signs show Ordinary Bronchitis, but it is peculiarly limited to 
one side, contrary to the rule of ordinary Bronchitis. Expiratory murmur is 
weak. The expulsion of a plug of fibrinous material gives great relief. 
Frequently we have a common chronic form. The patient is worn out, and 
dies of exhaustion. Plugs are found in the Bronchi after death. 

Rheumatic Bronchitis is not merely Bronchitis in rheumatic subjects, 
but is a Rheumatism of the Bronchial Tubes. The patient has a history of 
Rheumatism. Great pain attends acts of Coughing, which is very frequent 
and harsh. The Secretion is clear and mucus, and continues so a long 
time. It will not break up into a purulent effusion. This form is singularly 
connected with changes of Temperature. It is rebellious to treatment. It 
is cured only by Anti-rheumatics, together with Bronchial Treatment. It 
may present Metastasis. Under it we include the Bronchitis of gouty 
subjects. 



u8 

Diagnosis of Acute Bronchitis. We must observe certain precau- 
tions. There is danger of recognizing bronchitis but overlooking the 
Disease of which it is a Symptom, e. g., in Typhoid and Measles. We must 
ask ourselves is this Primary or Secondary ? Again, Acute Bronchitis may 
be confounded with Acute Tuberculosis of the Lungs. This may present a 
great deal of embarrassment, but its Bilateral Character, Mild Symptoms, 
will set us right. We may find Bronchitis limited to one side. This is the 
case generally when Bronchitis is Secondary in Malaria or Typhoid, or 
where there is some local weakness of the Lung, which may afterward 
develop Tuberculosis. It indicates a local vulnerability. 

The Prognosis in the ordinary form is good. In Capillary grave. In 
the Mechanical form it depends on the condition which it has followed. 

Treatment. Every patient demands Restriction to bed. He must not 
even be allowed to go about his room. A mild attack may thus be converted 
into a Severe. Talking and Excitement must be avoided, especially in old 
persons. Nervous Exhaustion may turn it into Capillary Bronchitis. Coun- 
ter-Irritation of a mild diffused character, e. g., Tincture of Iodine painted 
over each chest six or eight inches square or repeated Mustard Plasters 
applied twice or thrice a day. Turpentine Liniment. The yolk of an egg 
to a wineglassful of Turpentine and thinned with a Tablespoonful of Vinegar 
is good, but it is too strong for a child. It must be diluted with Cream or 
Water. Place this over the Chest. Then a layer of raw Cotton which may 
be stitched to the under shirt. If it is Capillary Bronchitis stitch oil skin 
outside. If there is a moderate Cough promote Expectoration. Fever 
should be met by Aconite or Veratrum Viride. Give Aconite in divided 
dose. For an adult gtt i every hour for seven hours. By the time gtt v are 
taken, we should have a marked effect. For a child five years old, give gtt 
iii in nine spoonfuls of water. Stop during the night and begin next day. 
We may combine a moderate amount of Quinine. If there is a tendency to 
run into the Capillary Form give Strychnia and Nux Vomica. The strain 
on the muscles of respiration must be relieved. Give Opium to stop the 
Cough or Chloral or Bromide of Potassium or Ammonium. It is best to pre- 
scribe the Opium in a separate form as the Deodorized Tincture or the Offi- 
cinal Solution of Morphin or for children, Paregoric. We may combine 
Opium, Ipecac, and Liquor Ammonii Acetatis or Citrate of Potash. This 
is relaxing sedative and alkaline. When the fever is subdued, we substitute 
Muriate of Ammonia and Brown Mixture. 

R Morph. Sulphat. gr. i, 

Syrup. Ipecac f^ii ss., 

Syrup. Scillas fgvi, 

Syrup. Prun. Verg. f^iss, 

Glycerin, ad fjiii. 

M. ft. 
In the Capillary form give Quinia, Carbonate of Ammonia, Nux Vomica. 
We must not use Opium. Various demulcent drinks, Rock Candy, etc., 
may be given. 

In the Fibrinous form give Carbonate of Ammonia and Iodide of 
Potassium to its fullest extent. 

In Rheumatic bronchitis try Salicylate of Soda, Iodide of Potassium, 
Carbonate of Potash, Vinim Colchici, Salts of Ammonia, Squill, Ipecac and 
Senega. 

i. Chronic Bronchitis. 

2. Winter Cough. 

3. Emphysema. 

4. Bronchiectasis. 

5. Asthma. 



121 

Chronic Bronchitis is a Chronic Inflammation of the Bronchial Tubes. 

Causes, i. It has a Geographical arrangement. The American 
climate favors it. Inhalation of irritating vapors. It is common in 
workers in mills, knife grinders, and persons who have to carry hot iron 
into the open air. It may be Chronic from the start, or arise from 
repeated acute attacks. Attacks of Winter Cough may each year last 
longer. Then the patient has it the whole year round. We have a Con- 
stitutional Susceptibility, which predisposes to congestion of the 
Mucous Membrane. All agencies which impair lung circulation, 
weak right heart, etc. 

Symptoms are Local and General. 

General are Cough, which is very troublesome, and is increased by 
change of Temperature, exertion of the voice, the inhalation of cold air, but 
not occuring like phthisis, in fixed spells for the removal of accumulations. 
This cough is more troublesome than that of Phthisis. The Expectoration 
may be stringy or tenacious. Hemorrhage is rare, yet when we have 
Emphysema it may occur. Respiration is not much quickened. The 
Pulse may be rapid and weak. Exertion produces shortness of breath 
and acceleration of the pulse. The effect on the General health varies. 
Some persons remain fleshy and plethoric, keeping the cough up many 
years. This is true of those subject to gouty Bronchitis. Others grow 
anaemic and lose flesh and strength. This varies with the spells of bron- 
chitis. We may have a series of changes extending over years. If there has. 
been dilatation of the bronchial tubes and purulent expectoration, we may 
have Night Sweats, great debility, and extreme Anosmia. 

Physical Signs, if it is Simple, are largely negative. Palpation is 
normal. Respiratory Murmur but little changed. There are Sibilent and 
Sonorous Rales, or large Mucous Rales, extremely variable in position.. 
Other changes are induced at length, e. g., Vesicular Emphysema. In 
Emphysema we have a globular chest, Exaggerated Vesiculo-Tympanitic 
Resonance, and Sonorous Mucous and Sibilant Rales around the base 
of the lung. Inflammation of a tube often extends to the tissue around the 
tube, and a hard mass is formed, which tends to dilate the Bronchial tubes. 
This Dilatation is of two kinds, Uniform or Saccular, i. In Diffused Dila- 
tation we find the Respiratory Murmur rough and blowing, both in Expira- 
tion and Inspiration. A lung may be Emphysematous or it may be thick- 
ened. 2. If Saccular Dilatation has been developed we have the signs of a 
deep-seated Cavity, Wooden Tympany, Exaggerated Vocal Resonance, 
Tubular, hollow, blowing murmur, both on expiration and inspiration. 
Quite often, from acute attacks of cold, the patient has asthma, i. e., spasm of 
the bronchial tubes. It depends on the nervous mechanism of the Bronchi. 

Duration varies from several months to fifty years. When there is puru- 
lent expectoration it may only last a few years. 

Diagnosis. A knowledge of the exact state of the Lungs is necessary. 
The disease with which Chronic Bronchitis is most commonly confounded 
is Phthisis, where the spots of Disease are small and scattered through the 
Lungs. We distinguish Bronchitis from Phthisis by — The age of the 
patient and the history of the case; the marked alterations from time to 
time; the rarity of hemorrhage; the absence of Bacith from the Spula; its 
amenability to treatment ; the absence of infiltration in the Lung tissue ; the 
absence of signs of softening or Cavity; the bilateral involvement. The 
physical signs of Bronchitis are very shifting. 

The Prognosis is uncertain, but not grave. Life may be prolonged 
indefinitelv. 



122 

Treatment is very complicated. The dress, residence, occupation, cli- 
mate, need attention. In all congested and inflammatory conditions change 
of climate can be recommended. The detection of the cause and its removal 
goes far towards putting the Treatment on a scientific basis. 

Remedies. Inhalations are most valuable. They may be made with an 
Atomizer using Carbolic Acid, Muriate of Ammonia, and Sulphate of Zinc. 
If the expectoration is foetid, Chlorinated Soda may be used. 
R Tinct. Iodine f^ii, 

Acid Carbolic f^ss, 
Spirit Chloroform f^ss, 
Tinct. Conii f^ss. 
M. ft. 

Put a few drops on the sponge of an Inhaler or we may use Pumice 
Stone which can be washed with Alcohol afterwards. Where we have reason 
to suspect Emphysema, let the patient breathe into an Exhausted receiver. 
Several kinds of Apparatus for this purpose can be procured. 

Internal Remedies. Order Cod Liver Oil, Arsenic, and Colchicum in 
gouty cases. Ammonia and the Alkalies favor Expectoration. Iodide of 
Sodium and Ammonium combined with Carbonate of Potash. Vegetable 
remedies such as Senega and Squills, which are stimulating, and Copaiba 
which is alterative as well. If we desire to stop the Expectoration, we use 
Sedatives such as Stramonium, Belladonna, Hyoscyamus, and Opium. 
Opium, however, should be avoided as much as possible. Strychnia and 
Mineral Tonics are useful to give tone to the System. 

Dilatation of the Bronchial Tubes may, as we have seen, be Uni- 
form or Saccular. 

Causes are those of common Bronchitis. The expectoration is copious, 
and if the Dilatation is Sacculated is foetid. Gangrenous Bronchitis is often 
associated. It is of long standing. 

Physical Signs. There is Diffused Blowing Respiration. Not rarely in 
the Sacculated form we find leaks at the roots of the lungs. Often the Lung 
itself may be contracted and Cirrhotic. This may impair the Resonance, 
but there is generally Emphysema, and consequently Exaggerated Resonance 
over the affected area. 

Prognosis. The lesion is incurable. 

Treatment is that of Chronic Bronchitis with the addition of Inhalations 
according to the character of the Expectoration. 

Emphysema occurs in many forms. In real Emphysema the air cells 
are permanently over-distended. It is usually associated with degeneration 
— the walls being often broken down. We have Atrophic and Hypertrophic 
forms. By Emphysema, we mean Vesicular Emphysema. It is inseparably 
connected with Chronic Bronchitis. 

Causes. Repeated violent efforts at Coughing. It may become asso- 
ciated with Sub-Lobular and Sub-Pleural Emphysema from Rupture of the 
Vesicles, and the entrance of the air to the Pleura. 

Morbid Anatomy. The Lung is very much enlarged. Its outline is 
altered. It is irregular. The distended vesicles may hang like Cherries 
from the sides. When grasped, it does not crepitate, but has a Cottony feel. 
It is paler than normal. The Circulation being impaired, we have an 
enlargement of the Right Heart. Atrophic Emphysema is where the Lung 
is contracted and indurated. Sometimes the Vesicles break and we have as 
a sequel Pneumo-Thorax. The air may make its way round and give rise to 
an Emphysema of the cutaneous tissue of the whole body. Violent efforts 
of Labor have caused it. It is a rare Complication of Emphysema. 



125 

Symptoms, i. The patient has had Chronic Bronchitis, but all 
evidences of Bronchitis may be wanting. We must not confound Emphy- 
sema and Bronchitis. Cough is not a symptom of Emphysema ; nor is 
Expectoration. 2. Habitual Dyspnoea, which is progressive and finally 
extreme. It is increased by talking, excitement, etc. There are no lesions 
of the Lung to account for the dyspnoea. The Explanation is easy. The 
Lung is so inflated that no new air can get in, and there is only just enough 
oxidation to supply the simplest wants of the body. The Chest is globular, and 
the Sterno Cleido Mastoid Muscle prominent. Respiratory Move- 
ments are changed. We have the up and down movement of the chest, 
but expansion and retraction are wanting. Percussion gives Exaggerated 
Resonance. The Apex is higher ; the base lower. This leads to the Liver 
being pushed aside. The Heart is overlaid and pushed to the right. The 
Spleen is displaced. Auscultatory sound is changed. There is a weak 
Inspiratory Murmur and prolonged expiration. Resonance and Fremitus 
are weak. 

Atrophic Emphysema. We find the same progressive Dyspnoea, but 
the Chest is Alar and Phthisical. The Lung is retracted. If the thickening 
is considerable, and the Emphysema in patches, we may have Impaired 
Resonance. There is a diffused blowing sound. No change in the adjoin- 
ing organs. As the Emphysema goes on the Heart and Circulation grow 
weak. Dropsy ascends from the feet. We have Congestion of the 
Kidney and transient Albuminuria. Rupture of the Vesicles may give 
Hemorrhage of moderate extent. The disease is unattended with Fever. 
There is distressing Pain in the Chest, and often Diaphragmatic Dis- 
tress. From time to time Spells of Asthma occur. Phthisis is often a 
complication. 

Diagnosis. We should look out for it in Chronic Bronchitis. When 
there is Dyspnoea, exclude Heart Trouble, Pneumo-Thorax, and Pleurisy. 
Fatty Degeneration of the Diaphragm is very rare. 

Prognosis. Emphysema progresses with fluctuations. If taken early, 
it may be cured. 

Treatment. Should be begun at once. The Indications are — 1. To 
cure the Chronic Bronchitis. 2. Allay the Spasmodic Condition. 3. Put 
the patient in the best general condition. 4. Aid the acts of respiration by 
some apparatus, which will give additional rarification to the air several 
times a day. 5. Associate with this careful Calisthenics. Young children 
may be cured by the adoption of Pulmonary Gymnastics. 6. Give ascend- 
ing doses of Strychnia and Arsenic as Respiratory and Muscular Tonics. 

Asthma is a name applied to paroxysms of Dyspnoea with wheezing. It 
is not Dyspnoea. A patient with Emphysema or Fatty heart may have 
Dyspnoea, but not Asthma. It is Spasmodic and is sometimes called " Spas- 
modic Asthma." It is divided into Bronchial, Cardiac, and Renal. This 
is only for Pathological clearness. It may occur with either. 

Symptoms. The attack is sudden. The patient is seized with Dysp- 
noea amounting to Apncea. He cannot lie down. The pupils are dilated. 
He is bathed in sweat. There is a terrible play of all the Respiratory 
Muscles. The Veins are distended. Expiration is prolonged and dim- 
cult, and accompanied by wheezing. The Pulse is rapid and weak. There 
may or may not be Cough. Inspiration is very feeble. There are 
Rales mostly sibilant, but if Bronchitis is present they may be moist. An 
attack may last from half an hour to seventy-two hours. An intense degree 
of Muscular and Nervous Exhaustion follows a prolonged attack. 



126 

Bronchial Asthma. There may be no evidences of Bronchitis in the 
interval. Some atmospheric change brings it on. Some take it on top of 
Bronchitis. It may occur in Emphysema. 

Renal. Any little increase of the malady, if there be a predisposition, 
gives rise to Asthma. The term Asthma has reference solely to the paroxysm. 
Asthmatics may present the tendency from childhood. It is sometimes 
inherited, and may be outgrown. It may be an idiosyncrasy. Some 
patients are thrown into Asthma by certain smells. Some can't live in 
the city ; others cannot live in the country. The most trivial Disturbances 
of Health may produce it, e. g., Eating Condiments, Shellfish, etc. 
The Diagnosis is easy. 

The Prognosis depends on the nature of the associated condition. 
Treatment of Asthma. We must consider the underlying condition. 
i. The Attack. In General the indications are to relax the spasm and 
relieve the Congestion and Catarrh. Spasm may be relieved by the Inhala- 
tion of Stramonium in Cigarettes. Espec's cigarettes are the best. These 
are composed of Belladonna, Hyoscyamus and Stramonium. Breathing the 
fumes of burning Nitre is a cheaper method. 

Internally, Lobelia, Bromides, Opiates, or Hoffman's Anodyne maybe used. 
R Tinct. Lobeliae gtt. cc, 

Amnion. Bromid. gr. cc, 

Spirit ./Etheris Co. f^x, 

Glycerin fSjss, 

Aquam, ad ff v, 

M. ft. S. : f£ii as required. 

This presents an Antispasmodic action and diffusible agents. If very 
severe give Opium separately, in Suppositories preferably, or as the Deodor- 
ized Tincture. Among inhalations we may mention Chloroform and Nitrite 
of Amyl. Belladonna or Atropia is valuable in Cardiac and Renal Asthma. 
In Renal we must avoid any remedy such as Opiates which would check 
Secretion. A minimum amount of Morphia with Atropia is valuable. 
Externally. Irritation by Dry Cups, Iodine, or Iodine and Croton Oil if 
there is much Congestion, followed by hot fomentations. Where Gastric 
Irritation is the cause, an emetic will break up the spell, and when there are 
large amounts of Mucus to be brought up. The Respiratory Muscles 
undergo partial paralysis, hence we give full doses of Nux Vomica and 
Strychnia, keeping up this for its tonic action. 

In the Interval treat for Cardiac or Bright's Disease. It may be, only 
Tonic Regimen is required. Iodide of Potassium in long courses, Arsenic 
in moderate doses, and Tartar Emetic in minute doses, have an alterative 
effect on the mucous membrane and remove morbid susceptibility. In true 
asthmatics, change of climate is most potent, and in the young it alone may 
be successful. This change is controlled by personal idiosyncrasy. Large 
cities do well for some, North Colorado for others. Sound Hygiene and 
Regimen are required. 

Atelactasis, or Pulmonary Collapse, is a Term applied to a retention of 
the Foetal condition. 

Carnification is where, from long pressure, air is driven out by a pleural 
effusion, and yet there is no inflammation. This is a good term. 

Hypostatic Congestion is a name applied to an import a7it clinical con- 
dition of the Lung, affecting chiefly the postero-inferior parts, where there is 
Engorgement, with or without infiltration, determined by Gravitation and 
Cardiac failure. It is seen in Low fevers and in Typhoid. The Lungs are 
purplish, heavy, very slightly crepitant, yet not hard. On section, bloody 



129 

serum, with bubbles of air, exudes. Compression removes it, and the Lung 
is not friable or softened. It is often mixed with Catarrhal Pneumonia or 
Bronchitis, Severe or Capillary, and we have the symptoms of Bronchitis. 
There may be more than Congestion. There may be a low form of Pneu- 
monia and an Exudation. This is Hypostatic Pneumonia. 

Causes. It occurs in weak, exhausted systems at the close of long dis- 
eases. It commonly follows Typhoid and Typhus, in the very old and very 
young. 

Symptoms. Respiration is more embarrassed. The hue of the face is 
dusky. The Pulse is frequent and weak. There is impaired Resonance 
over the postero-inferior part of the Lung. Respiratory murmur is weak, 
and Sub-Crepitant rales are heard on inspiration. If the Hypostasis is slight, 
putting the patient erect and making him take long inspirations may remove 
it ; the Crepitant Rale entirely disappearing from nervous exertion and pres- 
sure of the vesicles. 

Prognosis. In any condition in which it occurs it adds danger, and is 
sometimes the cause of death. 

Treatment is that of the disease which it accompanies. In Typhoid, 
it is due to a feeble condition of the heart. The tone of the branches of 
the Pneumo-Gastric going to the Lungs is lowered. Give Carbonate of 
Ammonium and Strychnia. The patient should not lie long in one position, 
Gravitation being a powerful factor. When the hypostasis is threatening 
and persistent, Electricity may be applied to the Respiratory Muscles. 

Pneumonia, i. Catarrhal. 2. Croupous. 

Catarrhal Pneumonia affects a group of cells. Hence it has been 
called Lobular or Insular. From its association with Bronchitis, it has been 
termed Broncho-Pneumonia. It is an inflammation of the alveolar walls, 
with an exfoliation of their [Epithelium. It involves scattered patches of 
Lung tissue on one or both sides, attended with a high grade of Mortality, 
occurring specially in the young and weak. 

Morbid Anatomy. It does not involve a whole Lung, but there are 
Nodules of inflamed tissue. The wedges are broader at their apex than at 
the centre. The inflamed patch is hard and stands out. There is often a 
little Pleurisy over it. On incision it is red. On pressure, friable. Under 
the microscope we see that the exudation is in the vesicles, and consists of 
Epithelial Cells, coagulated fibrin and leucocytes. The cells are variously 
changed, and the walls are affected by morbid processes. The Bronchial 
Tubes are inflamed, and lesions of Bronchitis co-exist. The tubes contain 
Mucus and Muco-Pus of different degrees of tenacity. With this we find 
patches of Collapse. The collapsed patches are dark, swollen and sunken. 
When inflated with a blow-pipe, the collapsed areas are restored. As the 
disease progresses, under favorable circumstances the exudation slowly softens, 
and Expectoration takes place. The Cells cease to proliferate, and the lung 
returns to its natural state. This is termed Cure by Slow Resolution. But 
the inflamed patch may soften and form abscesses under the pleura looking 
like Small Pox, or the exudation dries up and becomes granular, and we 
have a Chronic Induration, with cheesy change in the Exudation. There 
may be the formation of Tuberculosis through absorption of Septic material. 

Causes are those of Catarrhal Inflammation. 1. Exposure to damp 
and Cold when the system is run down. 2. Age. It occurs in the very old 
and in children. 3. A large proportion of cases are Secondary and con- 
nected with Measles, Typhoid, Whooping Cough, and Diphtheria. There 
may be very slight attacks. It may only be revealed at the Post-Mortem. 



130 

Symptoms in a Mild Case. We have Moderate Fever lasting for 
a few days which is generally higher in the morning. 101-5 F., or 102-5 F. 
Coated Tongue. Loss of Appetite. Heavy Urine. Some pain about 
the chest and Cough which is dry, severe, and bronchial. After a day or 
two there is grey expectoration. The Cough softens, and the expectora- 
tion becomes muco-purulent and then purulent. This may last fourteen 
days. If the lobules are few and but little affected, there would be no 
change in percussion or premitus. No blowing Sound. Perhaps a few spots 
of weakness and a few Crackling Rales which may only be heard on forci- 
ble expiration. If the patches are deep, as they often are, there are no 
physical signs. If the patient is not treated, the lesions extend and become 
unmistakable. Such attacks run into the distinctive changes of true Pulmo- 
nary Phthisis, and even Tuberculosis in those so disposed. A great many 
cases of Phthisis are of an inflammatory origin — slow Septic processes being 
set up. 

True Catarrhal Pneumonia usually arises in the course of severe Bron- 
chitis, but may arise primarily. 

Symptoms. Respiration is very rapid. Pulse rapid and disposed 
to weakness. Cough becomes more frequent and painful, and there is less 
Expectoration. Fever is very high, and presents remissions between day 
and night. The Skin may be moist. The Eyes are often congested from 
the fever, circulation, and Cough. There is Catarrh of the Intestinal tract 
and discomfort about the Epigastrium. The Tongue is foul. The Stools 
are irregular, costive, or loose. There is not that Flush on the cheek which 
we observe in Croupous Pneumonia. 

Physical Signs. Bronchitis has extended. Instead of Sonorous Rales, 
we have fine Sub-Crepitant Rales heard both on expiration and inspiration. 
Respiratory Murmur is weak, diffused, and blowing. Resonance is impaired, 
but there is not that flatness of Lobar Pneumonia. Vocal resonance has a 
Bronchophonic character. The consolidation is less extensive than in 
Croupous. In weak children we may have Collapse of the Lung. 

In a few days Nervous Symptoms appear. There is broken sleep, 
slight delirium, constant jactation. The appearance grows worse ; the lips 
livid ; features pale. The extremities are cool, though the central 
Temperature is high. The breathing is rapid and shallow; the pulse 
running and feeble. The heart is labored in its action, and its sound is 
weak. The skin is moist. The Physical Signs indicate extending Capil- 
lary Bronchitis and passive filling of the Lungs. We have a paralytic 
engorgement, as in Pneumo-gastric palsy. Vitality fails and Coma ensues. 
The patient dies of prostration and impeded Circulation and Respiration. 
The Duration of a case depends on its extent and gravity. A fatal case 
lasts four to five days, or it may run on to three or four weeks. Death may 
occur on the twenty-first day. 

Complications are not numerous. 1. Collapse is frequent. 2. Heart 
Failure from the prolonged High Temperature and interference with 
respiration. 3. Albuminuria is rare, and depends on the complication of 
Renal Catarrh. 4. Gastro-intestinal trouble — the mucous membrane 
sympathizing. 

Diagnosis. The chief point is the recognition of the possibility of its 
occurrence in Bronchitis and Blood diseases. It may be mistaken for 
irregular Malarial or Typhoid fever, with Bronchial complications. Give 
the patient the benefit of the doubt. 

Prognosis is very bad. From twenty-five per cent, to sixty per cent, 
die. The mortality, however, can be lessened if its onset is noticed and 
treated early. 



133 

Treatment is very unsatisfactory. It is difficult to lay down fixed rules. 
The indications are to relieve the Bronchitis, to maintain the circulation, to 
treat the stomach, and to favor resolution of the patches of exudation. As soon 
as its approach is discerned restrain the patient to bed. A mistake of two 
days may spoil the result. Put raw cotton' around the chest, and over it Oil 
Silk. Adapt the diet to the stomach. In order to limit the fever give 
moderate amounts of Quinine, if the stomach bears them well ; also Strych- 
nia and Mineral Acids. Avoid all weakening and nauseating remedies. 
Muriate or Carbonate of Ammonia for children, should be administered in 
Emulsion or Simple Solution. If there is a tendency to Heart failure, 
stimulants are called for. Turpentine is a valuable alterative expectorant 
and diffusible stimulant. It may be combined with alcohol. The disease is 
too diffused for counter-irritation. Iodine may be used over the whole 
chest. In children where there is great retention of mucus, an emetic as 
Sulphate of Zinc, or Ipecac, may be used ; but this should be avoided as far 
as possible. 

Croupous Pneumonia is an acute febrile disease connected with an 
inflammation of the Substance of the Lung, involving a considerable extent 
in which an exudation rich in fibrin, and red globules occurs in the vesicles 
without affecting the walls. The exudation is composed largely of coagu- 
lated Fibrin. It resembles the False Membrane of Croup. We have four 
stages. 

i. Congestion. 

2. Red Hepatization or Consolidation. 

3. Grey Hepatization or Softening. 

4. Evacuation. 

It terminates in Resolution, Abscess or Death. It usually affects the 
lower lobe of the Lung. It may involve only the posterior part of a lobe 
or may affect the whole lung. It may be double, and is then known as 
Double Pneunionia. 

I. Stage of Congestion. The Lung is acutely congested and full of 
red blood. The vesicles have a little exudation in them. 

II. Stage of Red Hepatization. The Lung is heavy. No air is 
admitted. It cuts like flesh on Section. If we press it with the blade of the 
knife a thick fluid comes out. It breaks down on pressure. If put into 
water it sinks. The exudation is from the blood vessels into the vesicles. 
It is composed of Globules, Leucocytes and a few Epithelial Cells. 

III. Stage of Grey Hepatization. The Lung is pale. On section 
the granulations disappear. There is Softening, and the exudation is less 
tenacious than during the first stage. The lung has undergone fatty degen- 
eration. 

IV. Stage of Evacuation comes on when the exudation is partly 
absorbed and partly expectorated. An abscess may form. There may be 
Thrombi, and Necrosis or Gangrene result from obstruction to the circula- 
tion. 

Nature and Causes. Some hold that Pneumonia is merely an Inflam- 
mation, others maintain that it is a Specific Disease. Pneumonia runs a 
definite course and terminates in a crisis, whereas, Inflammations generally 
subside gradually. In rare instances, it may follow violence, inhalations, 
etc., but this is not the case with Croupous Pneumonia. The peculiar dis- 
tribution of Pneumonia does not accord with the Climatic changes which are 
believed to produce it. On the other hand, Specific diseases are Symmetri- 
cal and Bilateral in their manifestations, e. g. t Small-Pox, whereas Pneumo- 
nia is most frequently unilateral. Pneumonia does run a Specific course, but 



134 

we find many variations. No positive opinion can be given. There is as 
much to be said in favor of one side as the other. 

Causes, i. Some assume a poison not yet separated. 2. Others, a 
Bacillus. 3. Others, the existence of a preparatory state of the system, e. g., 
Depression of nerve force. 4. Sudden climatic changes, Wet, Cold, Damp, 
etc. 5. Age. It is more a disease of adult life; old persons are very prone 
to it, yet children often have it. 

Varieties. Ordinary, Bilious, Cerebral, Malarial, Typhoid, and Sec- 
ondary. 

Ordinary. There is an abrupt onset, with Chill, followed by pain in 
the side, sharp and severe, from the association of Pleurisy. If there is 
less pleurisy, the pain is duller. It is increased by movement, pressure and 
coughing. There is a rapid rise of Temperature. It may reach 104 ° F. 
or 105 ° F., with only a moderate drop in the morning. At the close of the 
stadium it may drop 3 ° or 4 ° in twenty- four hours. The disease may gradu- 
ally terminate by defervescence. The Pulse is not so great as to accord 
with the Temperature. It is 96-115. Breathing is very rapid and labored. 
The nostrils play. The alae nasi move forcibly. The patient may have 
Orthopnoea. There is a great disproportion between the Respiratory and 
the Pulse rate. In an adult there may be 40, 48, 60 respirations per minute. 
Those of children may be 48, 72, or even 80. The ordinary ratio of Breath- 
ing to the Pulse is 18 to 72, or 1 to 4. Here it is 1 to 2, or even 1 to 1^. 
The patient seems ill from the start. The Expression is troubled. The 
Countenance flushed. The Flush on the cheek is on the same side as the 
Lesion. We have a dry, painful Cough, with at first no sputa. Then we 
have a little tenacious, glassy sputum, which soon becomes specked with 
points of blood. It looks like Iron rust. Fibrin is being brought away. 
It is so sticky that everting the cup which contains it does not empty it. As 
the disease advances and consolidation takes place, the Cough may stop and 
the Sputa again be dry, or fresh parts may be attacked and blood specks be 
brought away the whole time. When the disease is at its close, the expec- 
toration softens and becomes greyish. It ends in a soft muco-purulent fluid, 
and the Cough, at first hard and dry, becomes softer, looser and easier. 
Nervous Symptoms vary. Restlessness and wandering are common. 
The disease verges on a Typhoid type, with a tendency to twitching of the 
tendons, desire to leave the bed, muttering delirium. In children, when 
the upper lobe is involved, there may be active brain symptoms, followed by 
Coma. In children, Convulsions may occur at the onset or in the course of 
the disease. The Tongue is coated with yellow. There may be a little 
Vomiting. The Bowels are torpid, except there is Catarrh of the bowel, 
when there may be loose, bilious stools. The Urine is scanty, and has a 
heavy sediment, but there is an entire absence of Chlorides, Argentic Nitrate 
giving no precipitate. 

Physical Signs of Pneumonia. 

First Stage. Respiratory Murmur is feeble, partly from the pain caused 
by breathing. There is no change in Resonance or Fremitus. We hear a 
fine Inspiratory Murmur from the opening of vesicles coated with a fibrinous, 
sticky material. 

Second Stage. The Lung is hepatized and travelled by open bronchial 
tubes. Percussion is very dull and follows the course of a lobe or a lobe and 
a half. It is uninfluenced by any change in position. Vibrations in the 
Bronchial tubes come through to the hand better than normally. Thus we 
get increased Vocal Resonance and Fremitus. Auscultation reveals pure 
Bronchial respiration. There are no Rales. The exudation is too solid for 



137 

air to break it up. The chest movements are restricted. There is no push- 
ing away of the Liver, Heart or Stomach. 

Third Stage. Grey Hepatization. There is the same Dullness on Per- 
cussion. Vocal Fremitus and Resonance are increased ; but now we have 
Sub-Crepitant Rales, much coarser, larger and moister, heard both in expira- 
tion and inspiration. 

Fourth Stage. The Dullness lessens, the Bronchial breathing softens, and 
gradually th;e Lung returns to its normal condition. The Physical Signs do 
not disappear as quickly after the crisis as the Constitutional Symptoms do. 

Bilious Pneumonia. We have here a Complication of Gastro-Hepatic 
Catarrh. There may be little Jaundice with it. It occurs in the Tropics in 
the Spring and Fall. 

Cerebral Pneumonia may simulate the symptoms of Meningitis. It is 
generally associated with apicial Pneumonia. It is common in children and 
those disposed to Phthisis. 

Malarial is Pneumonia in a subject with Malarial Fever. A remittent or 
intermittent type is impressed on the Pneumonic Symptoms. 

Typhoid Pneumonia is where the symptoms run into a Typhoid char- 
acter. We have a marked prostration of the Nervous System. We find 
Flatulent distention of the bowel, Slipping down in bed, dry grey tongue, 
Muttering delirium. It occurs especially in the old and weak, or where 
there is some serious disorder of excretion at the same time, e. g., Nephritis. 

Secondary Pneumonia may occur in Typhoid and Rheumatic Fever. 
Diphtheria, etc. 

Diagnosis. Croupous Pneumonia may be mistaken for 

I. Catarrhal. We should remember the abruptness of Croupous ; Catarrhal 
Pneumonia being preceded by Bronchitis. Croupous affects a whole Lobe. In 
Catarrhal Pneumonia the Lesions are scattered. Croupous runs a definite, 
Catarrhal, an indefinite course. Catarrhal is three times as fatal as Croupous. 
The Chlorides are not absent from the urine in Catarrhal Pneumonia. They are 
in Croupous. Sputa are present in Croupous, absent in Catarrhal. Physical 
Signs in Catarrhal are not well marked except when the patches coalesce. 

II. Pleurisy. Pneumonia is more severe and the patient more ill. The 
alteration in the pulse is greater and the Fever higher. Physical Signs. In 
the First Stage of Pleurisy we hear a Friction Sound instead of the Fine 
Crepitant Rales of Pneumonia. In the Second Stage of Pleurisy, we have an 
enlarged chest, great difficulty of movement, and displacement of the Vis- 
cera. Effusion changes its place in Pleurisy. Vocal Fremitus and Reso- 
nance are weakened or lost. 

Prognosis of Croupous Pneumonia is good. An adult gets well in 90 to 
95 cases out of 100, if there is no complication. If the Pneumonia is Double 
or complicated with Pericarditis or Pleurisy, or if it occurs in drunkards or 
broken-down systems, and very aged people, it is very fatal. Yet, patients 
of 80 have recovered. Sometimes there is a tendency to Hyperpyrexia, e. g., 
above 105 F. This may arise from the violent inflammatory acuteness of 
the disease, or from the morbid condition of the Nervous Centres. Hence, 
heat is retained and accumulated. It is a dangerous Complication. 

Treatment. We do not follow any one plan. We speak of an ideal 
case, for which we can lay down certain rules. If we believe it to be a 
Specific Disease, we can only conduct our patient through its course. We 
can only break up an attack when there is Acute Congestion — not after that, 
/. e., once Consolidation has set in. The patient should be seen early. If 
there is high arterial tension in a person of good health, Venisection from 
the arm or copious Leeching to the side of the chest is advisable. This 



138 

should be followed by the immediate application of a cotton jacket inside 
the shirt, with Mackintosh outside. Push Veratrum Viride and Aconite to the 
point of positively affecting the Volume Force and Frequency of the Pulse. 
We should get a Softening of the Pulse and a relaxation of the surface. Give 
Fluid Extract Veratrum Viride, gtt. iii-v every two hours ; also Tincture 
of Aconite, gtt. iii. Moderate this the moment an impression begins to 
be produced, by lessening the dose and increasing the interval. There is a 
tendency to effusion into the Vesicles. Whether the nerves are palsied or 
not we do not know, but by checking the vis a tergo we stop the Exudation. 
Throw in full doses of Quinine. If the Stomach is irritable, give it per 
Rectum. If there is any absolute necessity give Quinine hypodermically. 
These measures, with absolute rest and rigidly restricted diet, may enable 
us to restore vitality to, and perhaps even cure a part of a lobe. The Diges- 
tive System must not be broken down. This treatment should not extend 
over two days. Then the area of Consolidation is known. The patient is 
now in for a siege of Fever and slow resolution. The treatment must now 
be directed to softening and hastening Resolution. Use at once Carbonate 
of Ammonia. It acts more quickly than the Muriate. Senega, Squills and 
Ipecac, nauseate. Give Carbonate of Ammonia, gr. v, or Muriate of 
Ammonia gr. vi-viii every two hours. Cough should be checked by Opium. 
This is also needed for Rest and Sleep. Do not mix it with the other 
medicine which is to be taken continuously. Quinine need only now be 
given in tonic doses, gr. vi-viii every three hours. Under the Cotton 
Jacket we may apply Tincture of Iodine. The diet should not be improved ; 
give Milk, Broth, etc. Continue this until the crisis comes and the Febrile 
Stadium is passed. Under this treatment 90 per cent, to 94 per cent, of 
cases recover. The fewer the drugs the better. 

Complications. In the very old and weak, and in children, we must 
avoid Venisection. Existing debility contra-indicates Cardiac Sedatives. 
Use Aconite alone, as being more controllable. Bilious symptoms make it 
necessary to attend, for the first few days, to the Stomach. Give Calomel, 
Bismuth and Soda; Aconite by the mouth and Quinine per Rectum. Push 
the Calomel in fractional doses till three liquid stools are obtained. Then use it 
only when there is Hepatic trouble. There may be Diarrhoea. This must 
be checked by the continuous use of Opiates. Sometimes Pain in the side 
is so severe that we must apply a blister over the spot under the Cotton 
Jacket. Poultice, and follow it with a greasy rag. It is better to reserve 
Blisters for the later stages. Nervous symptoms are often alarming, the 
patient being restless and not able to sleep. The cautious use of graduated 
doses of Opium prevent their appearance. Sometimes, however, it seems to 
increase them. Then use the Bromide Salts and Chloral. The Bromide of 
Potash is best : dose, gr. xv, at intervals, or gr. x with gr. v of Chloral. 
An Enema of Chloral in active Nervous symptoms together with Stomach 
trouble, is good. For a child, gr. v. ; an adult, gr. xv. If there is excess- 
ive Hyper-Pyrexia, we can scarcely hope to beat it down much. Our 
Remedies may increase it. If the Nervous symptoms are moderate, let the 
fever alone and go on with ordinary Treatment. In Pneumonia, Cold baths 
do not give favorable results. It is better to give colossal doses of Quinine, 
gr. xv, every three hours. Other drugs, notably Anti-Pyrene, have a won- 
derful effect, yet evidence so far does not enable us to say whether other 
results do not follow its use worse than the remaining Fever. The fever is 
only one Symptom of a complicated case. Cold applications to the head 
are good. A coil of rubber tubing with ice-water running through, ice bags, 
etc., may be left on several hours, and the effects watched. 



141 

Stimulants in Pneumonia. Alcohol is not required, but if it does not 
interfere with digestion, small amounts at short intervals with food, may be 
given to both old and young. Heart failure is thus less apt to occur. If 
there is marked weakness of the heart, the pulse weak and small, give first 
small and then large doses, to tide the patient over till the crisis comes to 
his relief. Children bear stimulants very well. Old persons require Wine 
Whey, Champagne, etc. Digitalis will suggest itself in connection with 
Heart failure. Give pretty full doses, with Ammonia Mixture and Quinine. 
We must not expect the same result on the Pulse as when Cardiac trouble is 
treated. Gtt. xii-xv of a good tincture, or f^i-ii of the Infusion will be 
enough. 

Pulmonary Phthisis is a term applied to a varying and complex set of 
symptoms, viz. : Cough, Expectoration, Hemorrhage, Fever, Sweats and 
Emaciation, associated anatomically with Ulcerative or Suppurative changes 
i?i the Lungs, which have been infiltrated by a peculiar Inflammatory product. 
The term Phthisis should not be applied to conditions till established organic 
disease of the Lungs exists. As to its nature views differ. It is mixed up 
with the obscure question of Tuberculosis. Some maintain that the areas of 
suppuration are areas of Tuberculous formation ; but we have no definition 
of Tuberculosis. Some authorities, like Koch, say nothing is Tuberculous 
in which Bacilli are not found. Opinions differ as regards the action of 
Bacilli, as to whether they are a cause or an effect, or whether the product 
of Tuberculosis offers a favorable nidus for their development. We do 
know, however, that there are areas of Lung infiltrated, and involvement of 
the peri-bronchial sheaths and alveolar walls. A new form of Lymphoid 
Tissue developes and infiltrates the area; then there are proliferations of the 
cells, after which Bacilli are found. The affected areas may be like Millet 
seeds, or quite extensive retrograde changes occur. There is very little 
blood supply. Cheesey Metamorphosis, Softening and Ulceration ensue 
and in the cavities thus formed Suppuration is kept up. We first have 
Infiltration, and when the areas coalesce, Consolidation. The ulcers often 
communicate with the walls of the Bronchi, and these may soften and 
ulcerate. The blood vessels of the diseased portion of the Lung are unpro- 
tected, and Aneurisms may form on their weakened walls. The Lung may be 
riddled by these areas, or one Lobe may be hollowed out into a large cavity 
with fibrous partitions. These changes begin at the Apex, usually involving 
only one Lung at first. They are nearly always associated with Pleurisy. 

Phthisis. 

Chronic, i. Catarrhal. 2. Fibroid. 

Acute. Croupous, Cheesey Pneumonia, Infiltrated Tuberculosis. 

In speaking of the varieties of Phthisis, we divide them clinically, and not 
according to the strict Pathology of each variety. Catarrhal is not neces- 
sarily a purely Catarrhal Inflammation. We have Tuberculous deposits in 
Catarrhal Products. So too in Fibroid, we find Tuberculous processes mixed 
with Fibroid products. 

Acute is simply Phthisis running only a few weeks or months. It is often 
called Galloping Consumption. It is not to be confounded with Acute 
Miliary Tuberculosis. Croupous Pneumonia may run into Phthisis, soften- 
ing, etc. 

Causes of Phthisis. We clearly recognize a state of preparation some- 
times inherited. To children a low form of Vitality is often transmitted, 
which renders them liable to phthisis. This state may also be acquired by 
all influences which depress the system. Early youth and early adolescence 
are times of formation. New tissue is being formed. Those who grow too 



142 

fast and who are precocious, are peculiarly liable. It often follows Im- 
paired Digestion and any exhausting Drain on the system. Those who 
are in this state get Phthisis from any inflammation. Where a subject has 
had old hard inflammatory products as scrofulous glands, absorption from 
these excites Phthisis. Some hold Phthisis to be Contagious. It may 
develop in a wife after the death of her husband from Phthisis, or in a 
mother after the death of the daughter, but such cases can be explained apart 
from Contagion. Whether it is contagious or not, is a momentous question, 
Clinically, Pathologically, and Socially. There are Local and Climatic 
Causes. Excessive Soil Moisture is a powerful agent. The character of the 
house and the ground on which it stands have a positive influence. 

Symptoms are — i. Early. 2. Late. 3. Physical signs. 

Chronic Catarrhal Phthisis. The Early Symptoms are paleness, 
impairment of appetite and nutrition, and slow loss of flesh. These 
may last for years before any Cough comes on. This is called the Stage of 
Incipient Phthisis. This is a bad term, as the phthisis may be broken up by 
proper means. Symptoms of Local Disease of the Lung may be called into 
play by a mere cold. The Cough is at first just slight and hacking. Then 
it becomes more troublesome. There is pain about the chest. The Tem- 
perature may rise one-half a degree in the afternoon. There is a slight 
acceleration of the Pulse. The Tongue is red at the edges and coated. 
Digestion is somewhat impaired. Sleep is disturbed, and the patient is 
restless. There may be a little Moisture at night. The patient loses 
flesh, gains a little, and then drops in 'weight. He becomes pale, and 
flushes easily in the cheek. The Temperature rises in the night, drops 
in the early hours of the morning, and rises in the afternoon. Night 
Sweats come on. The Cough is looser, and the Expectoration muco- 
purulent. The Pulse rises in rate, and the Breathing is accelerated. Not 
rarely the Extremities are cool, while the centre of the body is hot. There 
may be slight attacks of Diarrhoea. 

The Advanced Stage comes on when a Cavity has formed, and round 
it are spots of disease in various stages. The Temperature is always ele- 
vated. It runs up high on slight causes. The patient gets out of breath 
very easily. The Pulse is small and rapid. The Cough changes its char- 
acter and only comes on when the Cavity is full. There may only be a 
Coughing spell in the morning. Haemoptysis may be small or copious. 
Digestion breaks down more and more. The appetite fails and Diarrhoea 
is set up by slight things. 

Termination. The case ends in Tuberculous or Colliquative Diarrhoea. 
A patient may be cut off by a clot from sudden failure of the heart or by 
Dropsy. 

The Course varies from one to fifteen years, the average being two or 
three. There may be many fluctuations, which may be associated with acute 
Catarrhal attacks. Generally they accompany serious organic changes. 

Physical Signs. The Lesions of the early stages are generally found 
at the Apices of the Lungs, but not always. A patch may be even down 
below the root of the Lung. Percussion gives a slight relative impairment 
of Resonance. Auscultation shows that the Elasticity of the Lung is 
impaired. There is weak inspiration, prolonged and blowing expiration. 
Vocal Resonance is slightly increased.' If the patient coughs, and then takes 
a long breath, there may be a few scattered, crackling Rales. The Infiltra- 
tion progresses and we have the stage of Consolidation. Percussion shows 
marked Dullness. Auscultation reveals Bronchophony. We find both 
Increased Vocal Fremitus and Crackling Rales, because the process is not 



uniform. Then comes the Stage of Softening. Over the area of Con- 
solidation we now have moist Rales, which muffle the Bronchophony. 
Lastly we have the Stage of Evacuation. Cavities are formed, with 
Consolidation. On Percussion there is Tympany and the cracked pot sound. 
Auscultation gives Amphoric breathing. The Rales are large, mucous and 
bubbling. We hear Metallic Tinkling. The voice is pectoriloquous. In 
the stage of Consolidation and Softening there is Retraction of the Chest 
and Impaired Movement. The General Symptoms change more than the 
Local do. 

Fibroid Phthisis differs from Catarrhal in its longer duration, and in the 
absence of acute Catarrhal Inflammatory Spells. There is little fever for 
months. There may be none. Cough is apt to be extreme and wearying. 
Expectoration is white and copious Hemorrhage is by no means rare. 
Digestive disturbances and Night Sweats are not so common. The 
affected Lung has a large area. It undergoes Contraction. Cavities form 
round the centres of inflammation. The chest gradually retracts. The 
patient looks as if he had had Adhesive Pleurisy. Its mobility is much 
impaired. 

Physical Signs. Percussion gives hard wooden Resonance, with areas 
of tympanitic Resonance. Auscultation reveals a diffused blowing sound, 
with here and there cavernous breathing. In spots the Pleura is so much 
thickened that transmission of fremitus is interfered with. Vocal Resonance 
is increased and pectoriloquous, or it may be decreased. Rales are heard in 
the dilated bronchi. The Pleura may be so much thickened — one-quarter 
to one-half inch — that the transmission of Fremitus is interfered with. 
Vocal Resonance is increased and pectoriloquous, or it may be decreased. 

Acute Phthisis, or Galloping Consumption, is met with in Miliary 
Tuberculosis. We have an extensive Pneumonic infiltration, which takes on 
cheesey degeneration. 

Symptoms are its Duration — from one and a half to three or four 
months; the Course of the fever, which is high and continued, marked 
at times by breaks. The Breathing is weak ; the Pulse rapid. Cough 
may be very troublesome, or almost absent. Expectoration at times may 
be absent when the tubercles have not softened ; again it may be copious. 
Hemorrhage may or may not be present. 

Physical Signs, where the Lungs are studded with Tubercles, are 
obscure. Percussion reveals no dullness, Vocal Fremitus no change. The 
movements of the chest may be almost normal. Respiratory Murmur is 
altered and feeble. So many Lobules are obstructed that the amount of 
inspired air is small. There is consequently very little expansion. At times 
Vesicular Murmur may be shrill or hissing. Usually we have Crackling 
Rales at certain points, but the physical signs are out of proportion to the 
general symptoms of respiratory disturbance. When there is infiltration 
undergoing extensive changes we have signs of Consolidation breaking dozen, 
marked in either lung. Where the physical signs are very pronounced we 
have those of disseminated Tuberculosis. 

Special Symptoms. Cough is extremely important. It varies at 
different times as the disease advances. Patients will often deny that they 
have a cough. On interrogation we find that they raise mucus. This may 
be brought up by a very slight effort. On the other hand, Cough may be a 
most prominent symptom, and the amount of mucus raised be very small. 
Of course it is right that what pus is formed should be brought up. Cough 
for the removal of pus must not be checked, but a cough which wearies the 
patient, and is fruitless, must be stopped. As the disease advances cough 



146 

may only occur in spells, i. e., when the cavities are to be evacuated. Fre- 
quently the cough is aggravated by irritation from the larynx and pharynx. 
Troublesome cough helps to break a patient down rapidly. Sometimes we 
meet with cough which excites Vomiting. Patients will insist that it is a 
stomach cough. The stomach demands careful treatment, which will be 
followed by improvement in the cough. In the same way Expectoration 
should be studied carefully. In the First stage there is scarcely any. When 
softening begins it is muco-purulent, and finally becomes purulent. Expecto- 
ration may be absent. There may be extensive rales, and no mucus raised. In 
other cases, with small physical signs, there may be bronchial secretion in 
excess and copious expectoration. The sputa assumes what is known as the 
nummular form, solid, flat, heavy, round masses, which sink in water. This 
is more particularly met with in the later stages, when there is disintegration 
of Tissue. The Sputa of Phthisis have acquired an importance. The study 
of them after boiling with Potash is significant. The elastic tissue of the 
lung resists the action of the alkali, and its presence proves that the walls 
of the alveoli are undergoing disintegration. This diagnoses the case from 
chronic bronchitis. The presence of bacilli has a diagnostic value. In 
proportion to their number and growth is the progress and bad character of 
the phthisis. Hemorrhage repays careful study. It is a frequent symp- 
tom. Few cases go on without it. Some few do. Some bleed often and 
freely. The haemoptysis is easily recognized as coming from the Lungs by 
the character of the blood raised. It does not come up in gulps, like vomit- 
ing, but the mouth fills, and it is quietly spit out. The amount raised is 
generally very small. The Blood is arterial, fully oxidized, and frothy. 
Crimson froth lies on the top of the mucus. The amount is always exag- 
gerated. The mere amount rarely does harm. It indicates some fresh 
disease, which may result in more sputa and fever. It does no injury at the 
time. It comes from congestion around a spot already congested. This 
may occur at any period of phthisis, or the hemorrhage may arise from 
weakness of little pockets. Hemorrhages of these two kinds are followed by 
relief, especially the latter kind, after a hard, racking cough and fever. The 
patient feels better, the appetite returns, and the fever improves. In many 
cases of phthisis which bleed easily during the first stage the progress is good r 
and the case is slow and amenable to treatment, and the lesions do not 
advance rapidly. The vessels relieve themselves by hemorrhage, and not by 
exudation, which would fill up the lung and cause more disturbance. Other 
kinds of Hemorrhage may be dangerous. Small Aneurisms often form 
on the blood vessels along the walls, and cause death by bursting. Some 
blood stays, and if the lung is irritable, we have a sub-acute pneumonic con- 
dition set up. The Question arises, Can hemorrhage start phthisis itself? 
While it is true that hemorrhage from the Lung indicates organic disease, in 
a person strongly disposed to phthisis a blow on the chest may cause hemorr- 
hage and set up phthisis. People may have bronchial hemorrhage, in which 
lung tissue is not involved. It may come from the Larynx or Bronchial 
tubes. Their Mucous Membrane is thin, and the vessels break easily. Con- 
gestion following changes in atmospheric pressure may cause hemorrhage. 
In general, however, it is a symptom of evil omen. 

Pulse Rate is often accelerated before the physical signs are manifest. 
A continued acceleration and hacking cough justifies serious apprehension 
and radical measures. The absence of acceleration of the Pulse and elevation 
of Temperature is a very favorable symptom in phthisis. It means that Re- 
flex Irritability is not as great as usual; and, secondly, by the tendency to 
absorption of Septic material is not prominent. 



149 

Body weight should be studied carefully and regularly. When we add 
to elevation of Temperature and acceleration of pulse, body weight declin- 
ing, and a little hacking cough, we have dangerous symptoms. Nothing is 
more favorable than to find the body weight keeping equal. 

Diagnosis of Phthisis is easy with care. We might confound it with 
Chronic Bronchitis or Clironic Catarrhal Pneumonia. From Chronic 
Bronchitis we would diagnose it thus : The symptoms of Phthisis indicate 
greater constitutional disturbance. There is more weakness, fever, anaemia, 
Indigestion, Diarrhoea, Dyspepsia, etc., Night sweats and headache. Still 
with a large amount of Purulent Discharge and dilated bronchi, there may 
be the above symptoms. Physical signs are more reliable. There is no con- 
solidation in bronchitis, but dilated bronchi and Emphysema. Percussion 
Resonance is hardly affected, and may be exaggerated in Bronchitis. In 
Bronchitis, Vesicular Murmur is unchanged, and there maybe diffused blow- 
ing sound 'from general bronchial dilatation. In Bronchitis, we have feeble, 
inspiratory, and prolonged expiratory murmur. These are in both Lungs 
and diffused, but in Phthisis, it may be one-sided, or only in one spot. 
Hence, Localization is an important point. At one part there may be evi- 
dences of infiltration, Cavernous breathing, and change in vocal resonance. 

Rales in Chronic Bronchitis are Sibilant. In Phthisis they are at first 
Crackling, and in consolidation there are none. Again, they may be 
mucous, then bubbling, and then limited to one spot and spreading gradu- 
ally from it. If we have a case of phthisis where there are small centres of 
disease not running together to give consolidation to any extent, it may 
closely resemble Chronic Bronchitis. In the Diagnosis Elastic fibre and 
bacilli must be sought for. A very Important question is Recognition in the 
Early Stage. We may think it is only dyspepsia, anaemia, Malaria, and 
thus explain away the Symptoms. We diagnose by considering the Heredi- 
tary Tendency or evident acquired Constitutional weakness, Family history, 
age, Loss of flesh, Acceleration of Pulse, Temperature, Hacking cough, and 
then if there is repeated and critical examination of the chest, and it shows 
change at any point, though we cannot diagnose phthisis, we should keep 
the patient under observation and treat him carefully. This is the stage for 
Radical cure. After catarrhal pneumonia, minute areas remain, which may 
run into phthisis. We find a little impairment of Percussion Resonance after 
a coughing spell. On deep inspiration we may hear slight Rales. 

Prognosis varies enormously in different stages. It is fairly good in the 
very early stage if we can secure full control of the patient. After this, the 
Prognosis is bad. Life may be prolonged, but eventually the disease wears 
the patient out. Yet, even after positive Lesions are found, the Prognosis is not 
necessarily wholly bad. Consider — i. The Family History. 2. The Extent 
of the Lesion. Existence of any disease on the opposite side is very bad. A 
case is always worse if bilateral as indicating a tendency to Generalization. 
If the Stomach remains unimpaired, the patient can fight for a long time. 
Pecuniary means are of great service. Occupation, Climate, Mode of Life, 
must be changed, and all depressing circumstances avoided. 

Treatment of Phthisis. The most important part of the Treatment 
is Prevention, which should be both Individual and Municipal. Sanitary 
reform is needed in the Ventilation of Factories. Marriages should be 
prevented between phthisical persons, or coitus and conception prohibited. 
In the early stage health may be entirely restored. The Subject must be 
brought into physical vigor. Drugs should only be used as nutritives, or to 
check functional disturbances. We must recommend pulmonary Proper 



i qo 

gymnastics, and teach our patients to use the deeper parts of their Lungs, and 
to cultivate abdominal breathing. 

Drugs when used at all, should be adapted to the promotion of Secretion 
and Digestion, and to give tone to the system. Cod Liver Oil, Hyposphites, 
Iron, are all serviceable. 

Fully Developed Stage. Consider the tone of the patient, whether — 
i, to use a cautious conservative plan; or, 2, whether he is the stronger or 
the disease. If he is too weak for the above, let him either change his climate 
or start a protective plan. Rest in bed determined by his weight and tempera- 
ture, In-door exercise, Marriage, Artificial Feeding. Guard against Changes 
of Temperature. Use baths, gradually cooler and cooler, and friction. 
Insist on Out-door exercise. Stop his occupation, i. e., break the conditions 
which have led to the disease. Very often Phthisis will yield entirely to 
Gastric Treatment, by studying the Digestion and the Diet. Often the 
appetite is capricious. Here give acceptable food. Guard against the least 
tendency to diarrhoea. 

Cough is the patient's chief complaint. As a matter of fact, this is of 
no value. If it is fruitless and dry, we should attend to the Larynx and 
Fauces. Avoid Expectorants which are laxative and irritate the stomach, 
and use the simplest things. For Cough we give the following — 

R Morphise Sulphatis gr. i, 

Acidi Sulphuric Diluti, f«Jii, 
Syrup Pruni Vergin, fjiv. 
M. ft. S. A Teaspoonful in water two or three times a day. 

Or, instead of Morphia, we can use — 

R Potass. Cyanid, gr. iii, 

Acid. Muriatic Diluti, f^ii, 
Glycerin, f^ss, 
Syr. Pruni, Vergin : f^iss, 
Syrup Scillae, q. s. ad, f^iii. 
M. ft. Sign : A Teaspoonful in water two or three times a day. 

Avoid Expectorants in Phthisis. Mixtures of Senega, Squill, Tolu, etc., 
nauseate the patient. 

Night Sweats. We should endeavor to remove the cause by stopping 
Meat food and lessening the bed clothes, etc. Sometimes they depend on the 
irritation of the fever. Here give Atropia, y-L to -y-J-g gr., or join with the 
former prescriptions gtt x or xv of Aromatic Sulphuric Acid two or three 
times a day, or Gallic Acid 3 gr. and Quinia 2 gr., three or four times a 
day. Jaborandi in minute doses will tone up the Sweat glands, given in 
doses of gtt v three times a day. So will Sponging with Whiskey and Alum, 
or Alcohol, and rubbing with a dry salt towel. Change to a dry climate 
often breaks up Night Sweats. 

Haemoptysis need not excite solicitude. Huge doses of drugs to check 
it break the digestion down. Prescribe cool air in the bed-room, rest, a 
little Opium to tranquillize circulation, and a few drops of Ergot or Gallic 
Acid. If the stomach is irritable, give Ergot by hypodermic injections over 
the affected part or in suppository. Forbid all excitement. Digitalis is 
valuable as sustaining the heart's action and being itself an astringent. In 
cases of protracted Hemorrhage we may use Inhalations of Salts of Iron and 
Zinc by an atomizer. Do not push Opium too far. If Ergot does not stop the 
Hemorrhage within forty-eight or seventy-two hours, substitute Gallic Acid 
or Lead Acetate. Give Lead Acetate in gr. iii doses every three hours, and 
watch for Lead poisoning. In unusually protracted cases, Sulphate of 
Copper, gr. }i to gr. }£ does g°°d, aR d so will dry Sulphate of Iron. The 



153 

application of Ice over the Chest should only be given when large amounts 
of blood are being lost and where we want a powerful result. 

Fever. A moderate amount is to be expected. Apyretic cases are mod- 
erate. We can't get rid of it. It improves with the system, but sometimes 
may be exhausting. It may be associated with night sweats, and checking 
the fever may stop them as well. Keep the patient very quiet and restrict 
his diet. The effect should be prompt. We can't keep them in or on poor 
diet too long. Then give remedies, such as Quinia, Digitalis, Opium and 
Belladonna. Xiemeyer's pills are as follows : 
R Ouiniae Sulphatis gr. xl, 

Pulv. Digitalis, gr. x, 

Pulv. Opii gr. iii, 

Extract Belladonna? gr. iiss. 

Mft. Pil. xx. S. One three times a day. 
Break down the fever with Aconite in five doses of one drop each, or An- 
tipyrene, x or xii grains each, during the evening and afternoon. Some- 
times patients bear fever well and may go out with a temperature of 103 F. 
or 104 F., but we have rapid wasting of Tissue all the time. It shows a 
more intense infection of the system. Give Opium and Quinine to check 
it. We can't stop it, and other remedies only do harm. Don't give too 
many drugs. Only give them to meet special emergencies. Combine Extract 
of Malt, Cod Liver Oil, etc., with the food. Change of Climate. Some- 
times — 1. It is desirable to bring about a radical change in general state of 
of the System. 2. It may be required for relief of some special symptom. 
3. Simply for Euthanasia. Mere change of climate will lose its effect if the 
patients don't keep up same treatment as before. Forced Artificial Feeding 
has been recommended, but is no good. Rest, massage, and forced feeding 
may be good in a very simple case. Atmospheres of different densities 
and medicated seem to give some help. 

Local Treatment. Inhalations or Hypodermic injections into the dis- 
eased lung, are good where the disease is circumscribed, and there is a good 
deal of irritable coughing. 

THE PLEURA. 

Pleurisy is an Inflammation of the Pleural Membrane, which invests the 
Chest and covers the Lungs and Pericardium. It is a Serous Membrane, 
forming two closed sacks. We may consider it under the two forms of Acute 
and Chronic. Anatomically we consider — 1. Plastic Pleurisy. 2. Pleurisy 
with Effusion. We may further regard it under the two heads of — 1. 
General ; and 2. Local Pleurisy. Of the latter Diaphragmatic is a very 
interesting form. Under Special Forms we consider 

1. Idiopathic. 

2. Traumatic. 

3. Rheumatic. 

4. Latent. 

5. Tuberculous. 

6. Cancerous ; and 

7. Secondary. 

Acute Pleurisy may affect one or both sides. Sometimes the First 
Stage is followed by Plastic formation. There may be hardly any Serum. 
The whole Lung may be covered with plastic lymph, and present a reticu- 
lated appearance, with layers of false membrane. This lymph organizes, 
new vessels form in it, and we have what is known as Organized Lymph. 



154 

The layer may be one-qurter of an inch in thickness. Sometimes we have a 
large amount of yellow Serum, with little flocculi floating in it. It may fill 
the chest. The Lung is squeezed flat and the heart pushed to one side, or 
only two lobes may be compressed in the right lung, while the upper may 
resist the effusion. 

Encysted Pleurisy. The adhesions form partitions. In cases where 
the Diaphragm is bound to the under surface, the anterior margin of the 
Lung may come entirely around the Diaphraghm. Sometimes the effusion 
is so rich in lymph that pockets are formed all through the Lung. The effu- 
sion may be purulent from the beginning, or at first serous, and then the 
Pleurisy be converted into an Emphyema. After pleurisy has existed some 
time, if only a moderate amount of Lymph has been exuded, the Lung 
absorbs it, and the case recovers ; but if the Lung has been matted in the 
chest is drawn in, and we have the Deformity known as Retraction. Still 
worse is Purulent Effusion where a large collection of Pus has escaped. The 
Lung cannot expand, and we have permanent alterations, forming perma- 
nent inability to expand the Lung. 

Causes, i. Atmospheric Changes. Exposure to Changes of Tempera- 
ture. 2. It often follows blows, bruises, wounds, etc. This is Traumatic. 
3. When it develops in Rheumatism, it is known as Rheumatic. 4. It may 
come from so slight a degree of Inflammation that it is Latent. 5. The 
development of a Neoplasm or Carcinoma or Sarcoma, gives rise to Cancer- 
ous. 6. In Scarlet Fever, Pyaemia, etc., we have Secondary Pleurisy, and 
also in Bright's Disease. 

I. Simple Acute Pleurisy with Effusion. 

Symptoms. There may be slight Rigor followed by moderate fever 
102 F. to 103 F. Sharp Stabbing Pain in the side which is increased by 
moving, coughing, etc. It has given rise to the name Pleuritic Stitch. The 
Breathing is interfered with — is jerking and somewhat rapid. It is con- 
fined to one side. Constitutional Symptoms are Slight. The patient 
neither looks nor feels very ill. In reclining, he leans to the Injured Side. 
As the disease advances, the patient has less pain and lies on the Affected 
Side. The Effusion has occurred and separated the two layers of the Pleura. 
These layers do not rub against each other. In the first stage, Auscultation 
gives a dry brushing, Crackling, Superficial Friction sound, attended with 
sharp pain. Vesicular Murmur is impaired. In twenty-four hours, we may 
have signs of liquid Effusion. The Chest is enlarged. The Movement is 
exaggerated on the healthy side. Expansion is reduced over the affected 
spot. The intercostal spaces are prominent. Percussion gives a flat note 
over the affected area. This dullness varies with position. If the effusion is 
only moderate, instead of finding, as in Pneumonia, an oblique line corre- 
sponding to a lobe of the Lung, we have a wavy " S " shaped curve, or gen- 
erally it is horizontal. We have Flatness which varies with Position, and 
rises from the base. The upper line is horizontal. Vocal Fremitus is im- 
paired or lost. Vocal Resonance is Feeble or Absent. 

Fully Developed Stage. The affected side is filled entirely with the 
Effusion. The semi-circumference of the affected side, from the sternum to 
the Spine, is increased. The Intercostal Muscles are paralyzed, and the 
Intercostal Spaces are prominent. Percussion is Flat from base to apex. On 
the other side the Vesicular Murmur is Exaggerated. Now the Pleural 
Cavities are full, and change of position has no effect. The adjoining Vis- 
cera are displaced. On Auscultation there may be no breath sounds. There 
is much Dyspnoea, and with this we may have Tracheal Sniffling. Over 
Extreme Effusion we may hear a distinct sniffle, which may make us think it 



157 

is Bronchophony under our ear. Cases have been treated for Consolidation 
owing to this. If the patient breathes softly, we see there are no voice 
sounds at all. Vocal Fremitus is gone, and Resonance is feeble. The Dura- 
tion of the stage of increased Effusion closes in ten to fifteen davs ; then it 
is absorbed if it is serous. If the fluid has been purulent, there is no Absorp- 
tion. If Absorption takes place the Fever declines. The Pulse is slower, 
and the Breathing easier. During the stage of large Effusion there has been 
no pain ; now there is slight pain. The Viscera return to their Normal 
position, the size of the Chest is reduced, the line of Dullness fails, the 
Vesicular murmur returns, and we have a returning Friction Sound where the 
Costal and Visceral layers are rubbed together. Transmission of Voice is 
wholly abolished in Empyema, not entirely in Hydrothorax. Vocal Reson- 
ance gauges the progress of the Effusion. Where the Lung is partially Col- 
lapsed, we have coming through the thin layer of liquid a bleating, quavering 
sound called Aigophony. It is peculiar to the period when there is a thin 
layer of fluid. It is best caught over the Inter-Scapular region. The stage 
of Absorption lasts a week or ten days in favorable cases, but generally 
longer. It may run into a Chronic state and not be absorbed. These cases 
of Pleurisy are modified by the various forms mentioned above. We may 
have a considerable Effusion which is locked up in a sack and has a false 
membrane around it. This is Cystic Pleurisy. The general symptoms will 
not be Severe, for there cannot be much Effusion, but Physical Signs are 
modified, i. The upper line of Dullness is not horizontal, but follows the 
shape of the sack. 2. The Area of Dullness is not changed by position. 
Where we have a Multilocular Pleurisy we have pockets, uniformlv small, 
with Serum in them. We notice that the amount of Serum is small. 1. The 
Side is not swollen; and 2. The adjoining Viscera are Undisturbed. 3. The 
Area of Dullness is irregular. 4. It is not influenced by change of position. 
5. There is Flatness on percussion and Feebleness of Vocal Resonance and 
Fremitus, but they are not so entirely absent as in a large Effusion. 6. 
Vesicular Murmur is often feeble. 7. We have a transmitted Blowing Sound. 

The Duration of Encysted and Multilocular Pleurisy is uncertain. 
They are both Unfavorable to Absorption. In them we find an easy tran- 
sition to 

Plastic Pleurisy. Here we have the same General Symptoms, but the 
Area of Dullness is very irregular. We have a patch of Plastic Pleurisy, 
irregular in size and shape. There is much more persistent Crackling 
Friction. There is only Modified Dullness, not Flatness. Rarely is there 
great Dullness. Vocal Fre7?iitus and Resonance are not wholly lost, but of 
course they are impaired. Respiratory Murmur can be heard as a Weak, 
Blowing Sound. There is often associated with Plastic Pleurisy a slight 
Pneumonia of the Lung. Then there is Bronchial Breathing over such an 
Area, and the Vocal Resonance, as it comes to the ear, will be modified in 
character. The Course of Plastic Pleurisy is slow. 

Diaphragmatic is where the effusion is caught within the Diaphragm 
and base of the Lung. The Pain is extreme and referred to the base of the 
Chest and Diaphragm. It is associated with extreme Spasm of the Dia- 
phragm. It seems as if the patient would die of Suffocation. Hiccough 
is a most distressing Symptom. It may last ninety-six hours. The patient 
cannot sleep. The Heart may not be displaced, but its action is disor- 
dered in an unusual degree. The Inflammation may extend to the Vena Cava 
where that vessel passes through the Crura, and then we have ''Milk Leg." 

Physical Signs. If the Lung is entirely held down the effusion is con- 
cealed. There is no expansion. There is moderate displacement of the 



i 5 8 

Heart, and Lowering of the Liver and Diaphragm. There may be no Dull- 
ness on Percussion, as the Lung covers the effusion. There is no Friction 
Sound. There may be just a little relative Dullness. Vesicular Murmur 
may be present down to the Diaphragm. This is often overlooked. If the 
effusion involves part of the Costal Pleura we can get at the effusion. 

Purulent Pleurisy. The differences are rather in the General Symp- 
toms than in the Physical signs. The Physical signs are pretty much the 
same as in Encysted Pleurisy. The Pus may be free to move, or be in a 
pocket. We recognize Pus by the General Symptoms, i. The Fever 
does not subside ; it progresses, and rises higher and higher ; is hectic in 
type. 2. We have sweats at night. 3. The patient wastes ; is weak and 
sallow. 4. The Breath is sweetish and pyaemic in odor. These symptoms 
may come on any time. 

Diagnosis of Acute Pleurisy. We must Distinguish — 1. Myalgia of 
the Muscles of the chest Walls. The Patient is in pain, bends over, holds 
his side, etc. The Pain is increased by a Cough, by Movement, and by 
Breathing, but there is little Fever. The Pulse is not so frequent. On 
Auscultation there is no friction sound. There is no effusion to produce 
Dullness. Watch for a day and no Effusion occurs. 2. Pneumonia. There 
is more Chill ; more abrupt rise of Temperature ; more disturbance of breath- 
ing ; more flushing of the face. There is Crepitus on inspiration only, while 
the friction of Pleurisy is heard both on expiration and Inspiration. Yet, 
we sometimes cannot distinguish Crepitus from Friction Sound. In Con- 
solidation of Pneumonia, dullness follows a lobe of the Lung. Over the 
effusion we have a horizontal or (in case of Encysted Pleurisy) an irregular 
line of Dullness which changes with position. There is absence of Reso- 
nance or great weakness of Vocal Fremitus over the Effusion. When the 
Effusion fills the whole Chest and there is a transmitted sniffle, we might be 
misled. But we consider, the — 

1. Absence of Vocal Fremitus. 

2. Displacement of the Viscera. 

3. Enlargement of the Chest. 

4. Disappearance of Intercostal Spaces. 

These points Pneumonia cannot imitate. However, Multilocular Pleurisy 
and Encysted Pleurisy are more difficult. There is weakness of Respiratory 
Murmur as contrasted with the Broncophony, and Dullness is irregular, as 
compared with the regular lobar form of Pneumonia. In Pleurisy, there is 
an absence of Expectoration and no rusty Sputa. In order to make sure of 
our Diagnosis, we can use the exploratory needle. It does not hurt to run 
a needle into a Consolidated Lung ; therefore, we can use a Capillary needle 
and get enough fluid to satisfy our Diagnosis. 

The Prognosis of Acute Pleurisy is very good. In the encysted form it is 
doubtful as to duration. In the Multilocular Form it is doubtful. Some- 
times cases die from exhaustion if the amount of effusion is great. Acute 
Purulent Pleurisy is always dangerous. Our Prognosis should therefore be 
guarded. 

Treatment. Absolute rest in bed and protection of the surface. 
Restrict the diet. The disease is not wasting. The danger lies in the 
amount of the effusion. Give very little liquid. Venisection is never 
needed. In vigorous persons, where the patient is in very great pain, it 
might be advantageous, but generally local depletion by leeches or wet cups 
is sufficient. Then envelop the chest with cotton, oiled silk and Mackintosh. 
This must be arranged so that we can get careful Physical Examination every 
day. Opium is needed to relieve pain. Give hypodermic injections of 



i6i 

Morphia, with or without Atropia. We may administer Calomel, Opium 
and Digitalis for several days during the formation of the effusion. When 
it is clear that an effusion is formed stop this and use Alterative treatment. 
Iodide of Potassium with Digitalis, Acetate of Potash and Digitalis, or 
Iodide of Potassium and Jaborandi in the intervals; not enough, however, 
to produce Sweating. When the effusion is very large put on a Cantharides 
Blister 5x5, and let it "draw." Prick it and withdraw the Serum, and in 
ten days repeat it. This will generally bring an acute case to an end in 
three weeks. If the Pleurisy is plastic continue Calomel ; then Iodide 
of Potassium alone. Use smaller and smaller and more frequent Blisters. 
With Iodide of Potassium you may join Bichloride of Mercury, after stop- 
ping the mild Chloride. If you suspect Pus, puncture and aspirate at once. 
If Pus remains, bands are formed and a Pneumo-thorax may be produced. 
If Effusion increases in spite of treatment, distends the Chest, and displaces 
the Viscera, we may have sudden failure of the Heart. Therefore the 
existence of large Effusion, whether Serum or Pus, demands withdrawal. 
Sometimes the patient has Paroxysms of Dyspnoea, owing to encroachment 
on the Aorta, or from some Nerve being influenced. Operate at once in 
this case. If Effusion has been a long time, and will not go away in five or 
six weeks, then operate. All this time the Membrane is getting thicker and 
thicker, layers of plastic lymph are more numerous, and expansion will not 
be regained. 

Chronic Pleural Effusion. Hydrothorax is a term applied toa Watery 
Effusion where there is scarcely any inflammation. It is applied to a passive 
Dropsy in the Chest, connected with Heart and Kidney disease. Sometimes 
we have a Serous Effusion from a slight affection of the Pleura without 
inflammation. An acute case of Serous Effusion may not terminate in 
Absorption. Generally we get Pus, or, in other words, an Empyema. We 
meet with Chronic Pleurisy where Treatment has been faulty, and where 
there have been several attacks. Where the Patient's constitution is poor, 
or where we have a Tubercular Diathesis, Pleurisy may be secondary to 
Tuberculosis. The Effusion in Cancerous Pleurisy is apt to be blood-stained. 
The Effusion in Chronic Pleurisy may be free to move or encysted. 

Symptoms. 1. It may be Latent. It comes on insidiously. The 
patient gets tired from breathing. He may not even mention his Chest 
when he calls for medical aid, though the heart may be pushed to one side. 
People have fallen dead with the Chest filled to the Clavicle, yet never sus- 
pected it. While the symptoms are thus latent the Physical Signs are demon- 
strable : 1. The Affected Side is Enlarged. 2. The Intercostal Spaces are 
filled out. 3. Respiratory movements are abolished. There is, 4. Shifting 
Flatness. 5. Absence of Resonance and Fremitus. 6. The Viscera are 
nearly always pushed to one side in Chronic Pleural Effusion. The General 
Symptoms are well marked : 1. There is Shortness of Breath. 2. Pain 
on the affected side. 3. Inability to lie on the opposite side. 4. Dry Cough 
increased on talking or movement. 5. Some Fever, which is moderate in 
Serous, but Hectic and considerable in Purulent Effusion. 6. Failure in 
health, strength and color. 7. If the effusion has been long, oedema of the 
feet may come on from Heart Failure. W T e judge of the nature of the 
effusion by the amount and character of the Fever. Where there is Pus of 
long standing, the thoracic wall is cedematous. There is apt to be more 
severe pain and tenderness on pressure. Use the exploratory needle. 

The Course of the Case depends on the character of the effusion and on 
the condition of the chest. If the effusion is Serous, it may remain indefi- 
nitely. If Pus, it discharges itself by opening into the Bronchial tul>e> or 



1 62 

by an external Fistula. It may be vomited by the CEsophagus or perforate 
the Diaphragm. If the Lung is diseased, sometimes the effusion compresses 
it, and putting it at rest, has retarded the advance of the lesions. Hence we 
may be reluctant to disturb an effusion where the Lung is diseased. 

Diagnosis. It may be difficult to diagnose a Circumscribed effusion 
close to the Liver. We may mistake it for enlarged Liver. The history of 
the case, the conformation or otherwise of the Dullness to the shape of the 
Liver, the exploratory puncture, etc., will settle it. Sometimes it simulates 
Pericardial enlargement. However, a careful study of the Apex beat, the 
character of the Breath sounds, Dullness, etc., will set us right. 

Prognosis of Chronic Effusion if serous, is serious \ if Purulent, is dan- 
gerous. In Cancerous and Tuberculous pleural effusion, it is hopeless. 

Treatment. In Acute Pleurisy with effusion, even if it be Serous, and 
has lasted a long time, operate, i. e., where it has gone on for five or six 
weeks. Sometimes, of course, the symptoms demand early withdrawal of 
liquid. Put on a blister of Turpentine and confine the patient to bed. Give 
Iodide of Potassium and Digitalis, also a few sweats with Jaborandi, order 
rest and restricted Diet. If Phthisis is present, of course, give nothing to 
reduce the strength. If you have given a fair trial and no good results have 
followed, then perform Paracentesis. Paracentesis is usually performed by 
an Aspirator. If the Apparatus be dirty, it may turn a serous into a puru- 
lent effusion. Sometimes we have to tap five or six times before final absorp- 
tion takes place. Stop instantly when cough comes on, and the patient 
catches his breath. Do not be too anxious to obtain every drop of the fluid. 
After two or three tappings, if Pus still returns, pull out the Trochar and 
insert an India Rubber tube. Do this under Antiseptic Spray. Dress with 
Antiseptic Gauze, and outside put Mackintosh not only for the exclusion of 
Septic Material, but it enables Pus to be expelled with expiration, and no air 
can get in with inspiration through the Mackintosh. As the Lung expands 
towards the chest, withdraw the Rubber gradually and cut some off. In 
children, owing to the amount of Lymph and the thinness of the chest walls, 
we may have Retraction and Curvature of the spine. This will rectify itself 
in later years. Sometimes Secretion will not stop in Adults. Cutting out 
pieces of the Ribs so that the side caves in, has been tried, but this is an 
extreme measure. The best place for operation is outside of the Angle of 
the Scapula and as far down as we can without injuring the Diaphragm. 
The General Health of the Patient requires care. Tonics, Alteratives, Nutri- 
ents, etc., must be given. In Chronic Disease, as Bright's, we must remove 
the effusion. In organic Heart disease and Kidney disease, we, of course, 
keep up their own specific treatment. In Tuberculous Disease, complicated 
with Pleurisy, Operative Meddling avails but little. 

Pneumo-thorax. This condition is connected with Chronic Pleurisy. 

The Morbid Anatomy is Simple. It may be general or restricted to a 
very small area by bands of organized lymph. Pneumo-thorax often exists 
before Pleuritis, this being from an Empyema. An Empyema may burst 
into the Bronchi and air get into the Pleural Sack. Pneumo-thorax is a 
condition in which there is Pits and air in the Cavity of the Pleura. The 
Pleural Membrane presents symptoms of Inflammation, and with the Lymph 
we find an effusion of either Pus or Pus and Serum. The Lung is either 
totally collapsed or only one Lobe may be. If air has come from an ulcer- 
ated opening in the Pulmonary Pleura, a Fistula is found. In order to 
detect this condition, put a tube into the Trachea and blow into it, we find 
bubbles coming out of the Pleura and the point of injury is known. The 
adjacent viscera are displaced and the Diaphragm is pushed downwards. 



i6 S 

Causes, i. Wounds of the Chest. 2. A Fistula from an Empyema 
opening outside. 3. Rupture of the Pleura and the establishment of a 
Pulmonary Fistula. 4. It may come on in Phthisis where Sub- Pleural 
abscesses have formed and perforate. Phthisis would be a common cause 
for it, were it not for the adhesions formed between the Lung and Chest 
wall. 

Symptoms are those of a large Pleural Effusion of any kind. Dyspncea, 
pain in the Chest, Cough, without expectoration, coming on suddenly. 

Physical Signs. Distension on the affected side. The Intercostal Spaces 
are filled out. Displacement of adjoining viscera, especially the heart. 
There is altered or absent respiratory movement. Percussion gives very large 
tympanitic Resonance and Amphoric Sound, either circumscribed or general. 
Auscultation shows complete absence of breath sounds. There is no respira- 
tory murmur. But where we have a Pulmonary Fistula we have tubular 
Blowing and amphoric Breathing. If the hole is large, we may have large 
Cavernous breathing, and with this Rales and also Metallic Tinkling, caused 
by drops of Pus falling on the liquid below. The Rales are peculiar which are 
heard chiefly in this affection. If we sway the Trunk abruptly, we have 
a " succussion splash" which is characteristic. Vocal Fremitus and Reson- 
ance are lost. Only when we have a very large opening would we have 
Amphoric resonance. When Pneumo-thorax reaches a high degree, we have 
displacement of the Heart, with resulting Cyanosis, with Orthopnea and 
feeble pulse. 

Diagnosis is simple if the condition is not complicated with something 
else. The only trouble in Diagnosis is in Circumscribed Pneumo-thorax, 
especially on the left side. It may simulate Dilated Stomach. The tym- 
panitic note is hard to distinguish. In the Stomach we may have drops from 
the oesophagus falling on the liquid in the stomach. But the History of the 
case clears the matter up. There is here a history of Gastric symptoms. A 
very careful study will show that the quality of the tympany changes as we 
go from the Pneumo-thorax to the stomach. In the stomach the Resonance 
is the same throughout. Again, in Pneumo-thorax the tympany does not 
follow the shape of the stomach. 

Prognosis is good, if from a broken rib or a stab it gets well. In Empy- 
ema the prognosis depends on the primary disease. This is also the case in 
Phthisis. 

Treatment. We must stimulate the Heart and Respiratory organs. 
Strap the Chest from the Sternum to the Spine, and put that side at rest. 
When the Pneumo-thorax is very large, aspirate a moderate quantity of gas, 
and repeat this whenever alarming symptoms appear. 



VI. DISEASES OF THE DIGESTIVE TRACT. 

I. THE MOUTH. 

I. Stomatitis. 1. Aphthous Stomatitis is a disease of the mouth, 
characterized by little ulcers which form on the tongue, or cheeks, and lips. 
They are the size of small split peas, with slightly reddened rims and whitish 
surface. There may be only a few or many may be present. They are very 
painful, and may interfere with taking food in children. Apthse may be 
Idiopathic or occur at any period of life in connection with any disease of 
a grave cachectic character, as Cancer, etc. There are no complications. 



1 66 

They are easily recognized. The ordinary Apthae of children are easily 
treated by attention to diet. This is often sufficient for a cure. Or, a tonic, 
as small doses of Hydrochloric Acid and Pepsin may be given, or a powder 
of the Subnitrate of Bismuth and Pepsin; and if gastric irritation is marked, 
Nitrate of Silver in very small doses. Locally, dusting of Iodoform and 
Accacia is very useful. Light contact with Argentic Nitrate stick, or Sulphate 
of Copper may be made. In Cachectic Apthae we rely on local treatment. 

Diagnosis. We must distinguish it from Thrush which is a Fungus or 
Parasitic Stomatitis. It is a disease of childhood and is favored by indiges- 
tion and poor nutrition, but its special cause is Oidium Albicans. Its favorite 
seat is the mucous membrane of the mouth, but it may extend to the (Esoph- 
agus. There is much pain in aphthae. The dead white color and the elevated 
patch, and the use of the microscope would at once distinguish it from 
apthae. 

Its Treatment requires attention to diet, Tonics and local remedies 
calculated to destroy this fungus. The spots may be touched with Sulphur 
or a Saturated Solution of Iodoform and Ether. 

Prognosis. The disease is only serious when it is low down in the 
throat. 

Ulcerated Stomatitis. This appears in ill-nourished children, often 
in asylums, rarely in children of cleanly and well-to-do classes. 

Symptoms. The child is irritable, there is fever and great fetor of breath. 
There is dribbling of fetid saliva and great heat in the mouth. The gums 
assume a grayish hue. They are swollen and separated from the teeth. It 
suggests diphtheria and diphtheritic exudation, but it is not a true diphtheria. 
The glands under the jaw may be swollen. This is a very easily cured disease, 
but shows no tendency to heal of itself. Sometimes in true Diphtheria the 
exudation may appear to come from the mouth but it is really in the fauces. 

Treatment. Chlorate of Potash exerts a specific action. 

R Potassae Chloratis Z], 

Tr. Cinchonae Comp. f ^i, 

Syrup, Zingib. f^ij. 

M. S. : Teaspoonful every three hours. 

Give Tinct. Chloride of Iron and Quinia, Brandy and Port Wine. Local 
applications, as Chlorate of Potash and Borax, may be made with a swab, or 
the throat touched with a weak solution of Zinc Sulphate or acids. 

Gangrenous Stomatitis belongs to ill-fed, ill-nourished and depressed 
children. It follows on ill-nourished convalescence from Measles and 
Whooping Cough. 

The Symptoms are easily recognized. The disease attacks one cheek 
and there is a hard swelling. The exterior is glossy and red at the most 
prominent part. On the inside is an Aphagadenic ulcer, with indurated 
base, gray and sloughy. Its base is the thickened part of the cheek. The 
tendency of this ulcer is to perforate. It may spread and denude the bone, 
leaving a gangrenous hole, exposing the roots of the teeth. The constitu- 
tional symptoms are like those of gangrene. There is horrible fetor of the 
breath, loathing for food, decided pallor. The pulse is running and feeble. 
There is nervous prostration and decided pallor. 

Prognosis. This disease is generally fatal, or if recovery takes place, it 
is attended with shocking deformity. 

Local Treatment is most important. This consists in removing 
ulcerated portions by the application of pure Nitric, Hydrochloric or 
Carbolic Acids, so as to promote healthy granulations. The surrounding 
parts should be protected with lint soaked in oil. Mild applications will 



169 

not do. Pure Bromine has been used with success, but fuming Nitric Acid 
is best. Stimulants, such as Iron, Quinine and Turpentine, which has a 
healthy action in inflammations, should be given. 

II. THE THROAT. 

Acute Tonsilitis appears in three forms chiefly, Simple, Herpetic and 
Phlegmonous, but, as a matter of fact, we consider them under one heading 
practically. 

Causes are — 1. Early age. 2. Family; or 3. Personal Disposition. 
Some individuals have dozens of attacks. 4. Rheumatic; 01-5. Gouty 
Diathesis. 6. A run-down state of the system arising from Bad 
Air, Mai-Hygiene, Overwork, etc. 

The Morbid Appearances are seen by a direct Inspection of the Throat. 
For this the Tongue need not be thrust out. All that is necessary is to 
depress it with a spoon. Children frequently make no complaint, hence we 
should always examine the throat, even with entirely different symptoms. 

1. In the Simplest Cases we have Deep Redness and Swelling. There 
may be viscid mucus over the inflamed surface. 

2. Sometimes we have one or twenty White Points. This is called the 
Herpetic Form. There is no true False Membrane. The name of Folli- 
cular, or Herpetic, Tonsilitis is a good one. The points may be Unilateral 
or Bilateral. 

3. These points may or may not be present. We have Redness and 
Violent Inflammation, and we see little patches of False Membrane on the 
Mucous Membrane. This may complicate Tonsilitis. We give to it the 
name of Pseudo-Membranous Tonsilitis. It is a rare occurrence, but 
should be distinguished from Diphtheria. We may have Resolution — the 
little Follicles bursting and healing, or the Swelling may increase and Sup- 
puration may take place, and then the Tonsil is hard and unyielding to 
the Finger. This is known as Quinsy. There may or may not have been 
White Points. Chronic Enlargement may remain. The only associated 
lesions are those of the Pharynx and Lymphatic Glands at the angle of the 
Jaw. Those who have had one attack of Suppurative Quinsy are disposed 
to another. This is also the case with those who have had Herpetic Ton- 
silitis. 

Symptoms. There is often a Chill and General Malaise. High 
Fever up to 103 F. and 105 F. The Pulse is rapid. There is Severe 
Headache. Pain on swallowing. Tenderness and Pain at the angles of 
the Jaw. The Swelling may constitute a Distinct Tumor. The Tongue 
is coated and the Appetite lost. Vomiting is rare. In children the Ner- 
vous System is sometimes affected. Sleep is disturbed. The mind wan- 
ders, and there are Convulsions. In rare cases Temporary Erythrema 
is not extensive. There may be a temporary trace of Albumen in the urine. 
Disease lasts three or four, or may last seven to eight, days. It is longest 
when it terminates in Suppuration. The Abscess may not break of itself 
for ten days. The Symptoms grow worse till this Pus is discharged. The 
Case may look alarming. The Patient may be unable to swallow. 

Prognosis. This Disease always terminates in recovery. Suppuration 
might open the Carotid, or the patient might die from want of nutrition. 

Diagnosis. 1. We must exclude Scarlet Fever. This comes on with 
High Fever, Sore Throat and Swelling of the Glands. For a few hours the 
two are indistinguishable. Our doubt would be increased if there was a little 
rash. The throat symptoms of Scarlet Fever, however, don't generally 



I/O 

come on till the third day. Here the Swelling of the Tonsil is more rapid. 
The Fever is not so high, nor the Pulse so rapid, nor are the Nervous symp- 
toms so marked. Herpetic Patches do not appear in Scarlet Fever. Albu- 
men in the urine would be against Scarlet Fever. It is not found during the 
First Stage of Scarlet Fever. We must not be precipitate in our Diagnosis. 
If it is Scarlet Fever, the whole family is broken up ; and if it be in a school, 
a panic may spread. 2. Distinguish it from Diphtheria. Here we have a 
true False Membrane, not a distention of the membrane of the Follicles. In 
Tonsilitis the lesions are confined to the Tonsils. In Diphtheria the glands 
at the angle of the jaw are more swollen. Our diagnosis should be very 
cautious. The Term Diphtheritic Sore Throat should be abandoned. 

Treatment. In cases of Rheumatic Diathesis, Salicylate of Soda is a 
Febrifuge and Anti-rheumatic. Quinine is undoubtedly useful. It should 
be given in moderate doses. For a child five years old, gr. v., for an adult 
gr. xii. If the stomach is irritable give gr. ix. by Suppository. Where there 
are Herpetic Patches, Guiacum is useful in Emulsion or Lozenges. We may 
combine Chlorate of Potassium, or we may safely trust ordinary cases to 
Chlorate of Potassium. Tincture of Iron and Quinine at intervals of three 
hours. 

R Potass. Chlorat. gr. lxxx, 

Tinct. Ferri Chlorid, gtt. clx, 

Acid. Muriatic. Dil. f 3i, 

Syrup. Zingib. f ^ii, 

Aquam, ad f ^iv. 
Mft. Sign. : Teaspoonful in water every three hours. 

Locally we may use Externally, Iodine, and Internally Astringent and 
Sedative applications, as Tincture of Iron, and Glycerine, and Iodoform, 
dissolved in Ether. Both of these possess positive curative powers. Where 
there is plenty of Herpes, Iodoform is preferable. Gargle the throat with a 
saturated solution of Chlorate of Potash. Let pieces of ice dissolve in the 
mouth. Use the Steam Atomizer with Lime Water, Chlorate of Potash, 
Borax, Brocacic Acid. As soon as suppuration is expected puncture the 
Tonsil. An exploratory puncture is often serviceable as helping the Pus to 
reach surface. 

Hypertrophy of the Tonsils is quite common. It may come on 
suddenly, without any distinct symptoms. It is apt to develop in Rickety 
and Scrofulous children and patients disposed to Acute Tonsilitis. 

Symptoms. The movements of the soft palate are interfered with. 
The voice has a muffled, nasal and disagreeable character. The patient is 
apt to become a mouth breather. The entrance of the air to the Pharynx 
leads to Post Nasal Catarrh. It may interfere with chest development. 

The Treatment should be Dietetic and Hygienic — Dyspeptic derange- 
ment often lies at the bottom of this disease — and Local. The Tonsils may 
be painted with Iodine or a saturated solution of Iodoform in Tincture of 
Guiacum. Light applications of Nitrate of Silver, gr. xxx to an ounce. In 
acute cases we may inject Ergot, Acetic Acid or Iodine into the substance of 
the Tonsils, If it is hard and riddled with Sinuses it may be necessary to 
extirpate it, but we should try to save it if possible. After extirpation the 
base is frequently the seat of inflammation. To build up the strength give 
Cod Liver Oil with Lime, Iodide of Potassium and Syrup of the Iodide of Iron. 

Retro-Pharyngeal or Post Pharyngeal Abscess is frequent in 
children. 

Its Cause is sometimes Idiopathic Inflammation. More frequently it 
results from some deep-seated trouble, e.g., of the Cervical Vertebrae. 



173 

The Symptoms are Local pain and Inability to swallow. More or less 
interference with breathing, which is less if the abscess is above the glottis. 
There is swelling of the neck. The disease may continue some time before 
our suspicions are aroused. The finger may recognize the Fluctuation, or it 
may be so high up that we can see the abscess itself. 

Treatment consists in opening up the abscess with a curved bistoury 
guarded by adhesive plaster. The condition of the patient may be dan- 
gerous till it is cut. Death has resulted from delay. 

Diagnosis is easy. We should exclude mere laryngeal trouble and Spas- 
modic (Esophagus. We can hardly, however, make any mistake except 
where the abscess is very low down. 

P'haryngitis is Acute or Chronic, i. The Acute occurs under the forms 
of Simple Catarrhal, Follicular, Ulcerative, Phlegmonous, Gangrenous, and 
Tuberculous, and the special forms which occur in Scarlet Fever and Diph- 
theria with Pseudo-Membrane. 

Catarrhal. The parts are swollen, red, injected with viscid mucus, 
adherent in strings or patches. The Tonsils often sympathize, and the Folli- 
cles may be prominent or studded over. 

Causes are Atmospheric Changes. Exposure to Draughts. Over-straining 
•of the Voice. The sudden checking of perspiration. 

The Symptoms are Local Soreness, increased by swallowing and some- 
what by talking. A local sense of fullness causing an ineffectual effort at 
swallowing. Hawking and Removal of Viscid Mucus. There is a little swell- 
ing of the glands of the face and neck, but they are not so swollen as in 
Tonsilitis. There is moderate fever and some disturbance of the pulse. 

The Diagnosis in adults is easy but in children it may be overlooked 
from our attention not being directed to the part, and secondly, sore throat 
is an initiatory symptom of many specific diseases. Caution and reserve are, 
therefore, imposed upon us for a little time. At the start it is difficult to 
■distinguish Pharyngitis and Diphtheria. 

The Treatment is very simple. Impress on the patient the necessity for 
remaining in the house. Young and sensitive children should be restrained 
to one room or even to bed. Externally, various applications may be of ser- 
vice, e. g., Wrapping the throat with a pack of wet cloth covered with Oil Silk 
or Mackintosh. This relieves the pain and subdues the swelling, or we may 
bathe it with Chloroform Liniment. Internally we may paint the throat 
with Nitrate of Silver (gr. v to the ounce) or with Tincture of Iron (25 per 
cent, strength) or we may atomize it with either Lime or plain water. If 
the fever is pronounced give Saline doses and Tincture of Aconite followed 
by Quinine and Tincture of Iron. We may give a prescription of Chlorate 
of Potash and Iron. Where there is not much swelling, but great pain, we 
might suspect Rheumatism, and we could describe a Rheumatic Pharyngitis. 
Here use Iodide of Potassium with Potassium Bromide, also Salicylate of Soda. 

Acute Follicular Pharyngitis is only an aggravated form of Catarrhal 
Pharyngitis, but is more apt to run into a Subacute or Chronic form. 

In' Phlegmonous Pharyngitis, suppuration is apt to occur. It is 
really an acute Post Pharyngeal abscess. It is very rare. 

Ulcerative Pharyngitis is one of the Chronic diseases of this part, and 
is connected with Syphilis, Scrofula, etc. Syphilitic ulcers may occur in 
any part of the Pharynx, Tonsils or half arches. They are irregular and 
often quite large. They eat into the tissue and cause destruction. After- 
wards they may heal, leaving white puckered Scars with deformity. 

The Diagnosis is important. We may detect Syphilis by old Scars in 
the throat. Patients will show other and Constitutional sign>. 



1/4 

Prognosis. If left to themselves, they may eat away the entire Tonsil 
and both half arches. They may be followed by Cicatrization and union 
all the way across, producing occlusion ; or the posterior wall of the pharynx 
may be puckered, and the (Esophagus shut up. As they are not very pain- 
ful, they are likely to be overlooked. 

Treatment, Internally, should be a full course of Anti-Syphilitic remedies, 
e. g., Doses of a Salt of Mercury with Iodide of Potassium or Sodium in 
moderate doses. Locally we require powerful applications of Iodoform, in 
the form of powder or in a saturated Solution. Next come the Mineral 
Acids. Then Sulphate of Copper and Nitrate of Silver (gr. xx.-lx. to an 
ounce), or a few touches with the solid stick. Surgical measures are some- 
times necessary, and we must open the ulcers with a Galvano Cautery. 

Tubercular Pharyngitis. In a case of tuberculosis, ulceration of the 
Pharynx may occur. It is apt to be associated with Tubercular Pharyngitis. 
Generally, Pulmonary Tuberculosis precedes it. We have miliary Tubercles 
with a shallow, round, irregular, white base, resisting treatment, and very 
painful. It is rarer in the larynx than in the pharynx. 

Treatment. Apply Iodoform and other Alteratives. This relieves the 
pain and produces an alterative action, which is very useful. Other Altera- 
tive applications are useful to relieve pain and prevent progress of the ulcers. 

Prognosis. They may heal, leaving a scar; but generally they advance 
with the condition of the lungs, and terminate fatally. The commonest 
Pharyngeal troubles are the Catarrhal and the Follicular. 

II. Chronic Sore Throat. This arises from repeated attacks imper- 
fectly cured, or it may result from long-standing inflammation. The most 
frequent cause is Mouth-breathing from Nasal Obstruction. This may be 
Congenital, or arise from over-use of the Voice. It goes by the name 
of "Clergyman's Sore Throat" and " Singer's Sore Throat." If the sys- 
tem is relaxed and run down this cause acts with double intensity. The 
American climate is irritating to the throat. 

The Symptoms are : A feeling of fullness and discomfort in the 
back of the throat, accompanied by frequent hawking and the discharge 
of mucus amounting to a considerable quantity in a day. The voice 
becomes guttural, coarse and thick. There is morbid sensitiveness and 
inability for prolonged speaking. 

The Diagnosis is easy. There is no difficulty of recognizing it by the 
enlargement of the follicles and the excessive secretion of glairy mucus. 

Prognosis. It is not a grave disease, but in some cases, if it runs on, it 
may necessitate abandonment of work. 

Treatment. We must search for the exciting cause. This may be a 
nasal hypertrophy or a post-nasal catarrh. Study the patient's elocution, 
peremptorily forbidding scraping of the throat. This alone often cures it. 
Gymnastic exercise, friction, sponging, and attention to ventilation are of 
inestimable benefit. We may take this affection as an admirable text for 
relieving general pharyngeal troubles. Administer Tonics, such as Quinine, 
Mineral acids, and Strychnia, for Systemic relaxation. Where there is 
much swelling and infiltration, the local application of Mineral Astringents, 
such as the Sulphates of Zinc and Copper, and Tannic Acid, are useful. 
The Faradic Current will restore tone to the muscles. 

III. THE CESOPHAGUS. 

The CEsophagus is not subject to many affections. The most common 
are Spasm, Obstruction and Paralysis. 



*77 

i. In Spasm we have a Functional Condition brought about by a slight 
scratch or by swallowing things too hot, or it may be Reflex, as in Uterine 
and Gastric troubles, or it may be an accompaniment of Hysteria. 

Its Symptoms are an Inability to Swallow. The patient finds him- 
self suddenly unable to swallow nourishment. The act of deglutition brings 
on a spasm. 

Diagnosis. This condition is recognized by the General History, but 
more particularly by the fact of an ([Esophageal Sound or Bougie passing 
easily into the stomach. During the spasm the oesophagus grasps it, but 
lets it pass upon pressure. "We can never make a mistake. 

The Prognosis is favorable. 

The Treatment consists in the removal of the cause and the administra- 
tion of Antispasmodics and Tonics ; Regimen to get rid of any Hysterical 
tendency, and the gradual dilatation of the oesophagus by the constant 
passage of the Bougie. If it is associated with Uterine disease, Counter- 
irritation over the Ovaries, Uterus, <xx. 

Organic obstruction may arise from very many Causes, e. g. — i. 
Aneurism of the Aorta may press the (Esophagus against the Spinal 
Column. 2. Enlargement of the Bronchial Glands. 3. A Caustic 
Substance swallowed by mistake may cause occlusion of the lumen. 4. 
An Ulcer may by Cicatricial Tissue close the opening. 5. Neoplasms 
may obstruct the passage. Of these, Sarcoma and Cancer are the most common. 
They are apt to be found at points rather high up : at the level of the 
Larynx, at the bifurcation of the Trachea and at the Cardiac end of the 
Stomach. 

Symptoms. 1. Slowly progressive impairment of Deglutition. 
Solids in large, then in small pieces, thick and lastly even thin liquids will 
not go down. 2. This condition fluctuates. These fluctuations are due 
to temporary irritation associated with spasm. Occasionally the onset is 
more sudden than would seem possible. A person on sitting down to a meal 
finds he cannot swallow. A very highly-seasoned or hot article causes 
spasm and first attracts his attention. In many cases, however, the condition 
has been imperceptibly gradual, and we must not attach too much weight 
to the statements of the patient with regard to the abruptness of the onset. 

3. Next comes Pain. This is worst in cancer. It differs in intensity ac- 
cording to the seat. It may be referred to a point opposite the obstruction. 

4. The Bowels are obstinately constipated. 5. The Face becomes pale. 
6. The Body wastes. 7. Food is regurgitated. The oesophagus be- 
comes dilated above the point of obstruction. Food becomes lodged 
there, and when it returns it may be mistaken for vomit. 8. If the back is 
ausculted during swallowing a liquid, we find a point where the ordinary 
rapid, smooth gurgling is replaced by a noisy churning sound, and then 
followed by that of liquid passing through an orifice. 

The Diagnosis has reference to — 1. Its Existence. We distinguish it 
from Spasmodic obstruction by the progressive nature of the Symptoms, 
by the result of passing the Sound, by the history of the case, and the condi- 
tion of the patient. 2. Its Nature. We must exclude Aortic Aneurism. 
This condition must always be borne in mind, and before making trial with 
the Bougie, the Heart and the Ascending and Descending Aorta should be 
carefully examined. Intra-Thoracic Tumors must also be excluded. In- 
quire into the history of the case. Has there been injestion of hot liquid^? 
Swallowing of a sharp body? Is there a history of Syphilis? Any heredi- 
tary taint? If there is Cachexia, does the presence of Morbid Growths 
elsewhere justify the assumption of its being of a malignant nature. 3. Its 



i>8 

Location is determined by watching the effect of swallowing, and by the 
careful use of the (Esophageal Bougie. 

The Prognosis depends on the cause. »Even in the case of Cancer life 
may be prolonged by appropriate treatment. 

Treatment is Dietetic. Strict attention must be paid to food. The 
proper use of judiciously prepared Enemas to maintain the strength. If 
dependent on syphilis, we should endeavor to check this disease. In all 
other cases Internal Treatment is not indicated. Dilatation must be prac- 
ticed. Where the obstruction is from a Neoplasm we can only retard it by 
keeping the channel patulous. Even in Cancer we may thus obtain in- 
creased ease in swallowing. In some cases the use of a false oesophagus 
made of rubber has been found useful for the administration of peptonized 
food. The mere pressure of the tube favors dilatation. When the obstruc- 
tion is very high up, Excision has been performed. Such an operation 
requires extreme skill, and is often useless. However, the establishment of 
a Gastric Fistula has been successful in some cases, and promises to consider- 
ably prolong life. 

III. Paralysis of the (Esophagus, i. e., loss of power, arises from a 
Failure of Vitality at the end of Low and Brain Fevers. It exists as a 
symptom in Labio-Glosso Pharyngeal Paralysis which arises from an affection 
of the root of the Glosso-Pharyngeal Nerve. Here it is only a part of a 
hopelessly progressive condition. Sometimes articulate speech is lost while 
the (Esophagus still retains its power. After Diphtheria we often find Paralysis 
of the (Esophagus very troublesome. It may also be present in Hysterical 
cases. 

Symptoms. Food enters the Larynx and induces a fit of coughing. 
This may be so marked that it is impossible to feed the patient. Sometimes 
a litttle food may go down. 

The Diagnosis is made by first excluding obstruction, and then studying 
the history of the case. 

Prognosis. At the end of Brain Fevers patients are rarely saved. 

Treatment. Electricity and Rectal injections of food may retard death. 
The application of insulated conductors to the walls of the chest is important. 

( Continued in Part II ) 



